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Sharawat IK, Panda PK, Ramachandran A, Bhadoria AS. Cost-effectiveness of adrenocorticotropic hormone injection and oral prednisolone in patients with West syndrome: A comparative analysis. J Neurosci Rural Pract 2023; 14:103-110. [PMID: 36891085 PMCID: PMC9943942 DOI: 10.25259/jnrp-2022-6-31] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/20/2022] [Indexed: 12/23/2022] Open
Abstract
Objectives This study aims to compare the cost-effectiveness of oral prednisolone and adrenocorticotropic hormone injection in West syndrome patients, the two most common hormonal therapies used for this condition. Materials and Methods In this prospective and observational study, we documented sociodemographic, epilepsy, and development-related variables at baseline and up to 6 months after starting hormonal therapy, in all consecutive eligible patients of WS between August 2019 and June 2021, apart from the direct medical and non-medical costs and indirect health-care costs. We selected cost per quality-adjusted life-year (QALY) gained, per one patient with spasm freedom, one positive responder (>50% reduction in spasms), one relapse-free patient, and one patient with development gain. We determined whether incremental cost-effectiveness ratio for these parameters crossed the threshold value in base-case analysis and alternate scenario analysis. Results Out of 52 patients screened, 38 and 13 patients enrolled in ACTH and prednisolone group. On D28, 76% and 71% achieved spasm cessation (P = 0.78) and the total cost of treatment was INR 19783 and 8956 (P = 0.01), in ACTH and prednisolone group respectively. For all pre-specified parameters, the cost/effectiveness ratios including cost/QALY gain were higher in ACTH group and the corresponding ICER values for all these parameters crossed the threshold cost value of INR 148,777 in base-case analysis and also in alternative scenario analysis. Conclusion Treatment with oral prednisolone is more cost-effective as compared to ACTH injection for children with WS.
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Affiliation(s)
- Indar Kumar Sharawat
- Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Prateek Kumar Panda
- Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Aparna Ramachandran
- Department of Neurology, IQRAA International Hospital and Research Centre, Kozhikode, Kerala, India
| | - Ajeet Singh Bhadoria
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Zhu HM, Yuan CH, Luo MQ, Deng XL, Huang S, Wu GF, Hu JS, Yao C, Liu ZS. Safety and Effectiveness of Oral Methylprednisolone Therapy in Comparison With Intramuscular Adrenocorticotropic Hormone and Oral Prednisolone in Children With Infantile Spasms. Front Neurol 2022; 12:756746. [PMID: 35002921 PMCID: PMC8727336 DOI: 10.3389/fneur.2021.756746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/26/2021] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose: To assess the safety and effectiveness of oral methylprednisolone (oMP) in comparison with intramuscular adrenocorticotropic hormone (imACTH) and oral prednisolone (oP) therapies in children with infantile spasms (IS). Methods: In this prospective, open-label, non-blinded, uncontrolled observational study, children (aged 2–24 months) with newly diagnosed IS presenting with hypsarrhythmia or its variants on electroencephalogram (EEG) were included. It was followed by imACTH, oP, or oMP (32–48 mg/day for 2 weeks followed by tapering) treatments. Electroclinical remission/spasm control, relapse, and adverse effects were evaluated in the short-term (days 14 and 42) and intermediary-term (3, 6, and 12 months) intervals. Results: A total of 320 pediatric patients were enrolled: 108, 107, and 105 in the imACTH, oMP, and oP groups, respectively. The proportion of children achieving electroclinical remission on days 14 and 42 was similar among the three groups (day 14: 53.70 vs. 60.75 vs. 51.43%, p = 0.362; day 42: 57.55 vs. 63.46 vs. 55.34%, p = 0.470). The time to response was significantly faster in the oMP group (6.5 [3.00, 10.00] days vs. 8.00 [5.00, 11.00] days for imACTH and 8.00 [5.00, 13.00] days for oP, p = 0.025). Spasm control at 3, 6, and 12 months was also similar in the three groups (P = 0.775, 0.667, and 0.779). The relapse rate in the imACTH group (24.10%) was lower than oMP (30.77%) and oP groups (33.33%), and the time taken for relapse in the imACTH group (79.00 [56.50, 152.00] days) was longer than oMP (62.50 [38.00, 121.75] days) and oP groups (71.50 [40.00, 99.75] days), but the differences were not statistically significant (p = 0.539 and 0.530, respectively). The occurrence of adverse effects was similar among the three groups. Conclusions: The short and intermediary-term efficacy and recurrence rates of oMP are not inferior to those of imACTH and oP for the treatment of IS. Significantly, the time to achieve electroclinical remission with oMP was quicker than that with imACTH and oP. Considering its convenience, affordability, and the absence of irreversible side effects, oMP can serve as a form of first-line treatment for newly diagnosed IS.
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Affiliation(s)
- Hong-Min Zhu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Hui Yuan
- Department of Laboratory Medicine, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meng-Qing Luo
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Rehabilitation Medicine, Wuhan First Hospital, Wuhan, China
| | - Xiao-Long Deng
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Huang
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ge-Fei Wu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia-Sheng Hu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cong Yao
- Health Care Department, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhi-Sheng Liu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Barash G, Bassan H, Livne A, Benyamini L, Heyman E, Bowman P, Rachmiel M. Novel perspectives of super-high dose sulfonylurea and high-dose oral prednisolone in an infant with DEND syndrome due to V64M heterozygote KCNJ11 mutation. Acta Diabetol 2021; 58:1665-1672. [PMID: 34272607 DOI: 10.1007/s00592-021-01763-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022]
Abstract
AIMS To report a novel mutation associated with developmental delay, epilepsy, and neonatal diabetes-DEND Syndrome, responsive to a novel management combination. METHODS We describe the investigation, treatment, and genetic diagnosis of a newborn diagnosed with DEND syndrome. RESULTS The patient was found to be de-novo heterozygous for pathogenic KCNJ11 missense variant: c.190G > A, p. (Val64Met), associated with DEND syndrome, responsive to a combination of super high doses of sulfonylurea (SU) and oral high-dose steroids. A single case was reported so far due to this mutation, presenting with severe DEND syndrome, treated by insulin only. His phenotypic description and management during 18 months, demonstrates this mutation is responsive to super-high doses of SU combined with high dose 6 weeks steroids protocol. CONCLUSIONS We have identified a heterozygous missense mutation as the etiology for severe DEND syndrome in a one-day old neonate, presenting with asymptomatic hyperglycemia, responsive to a novel management combination.
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Affiliation(s)
- Galia Barash
- Pediatric Endocrinology and Diabetes Institute Shamir Medical Center, 70300, Zerifin, Israel
| | - Haim Bassan
- Pediatric Neurology and Development Center Shamir Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Livne
- Neonatal Intensive Care Unit Shamir Medical Center, Tel Aviv, Israel
| | | | - Eli Heyman
- Pediatric Neurology and Development Center Shamir Medical Center, Tel Aviv, Israel
| | | | - Marianna Rachmiel
- Pediatric Endocrinology and Diabetes Institute Shamir Medical Center, 70300, Zerifin, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Wanigasinghe J, Arambepola C, Murugupillai R, Kapurubandara R, Jayawickrama A. Quality of life at 6 years in children treated for West syndrome with hormonal therapy. Epilepsy Behav 2021; 119:107974. [PMID: 33946008 DOI: 10.1016/j.yebeh.2021.107974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION West syndrome is a severe epileptic encephalopathy occurring in infancy. Majority of affected children suffer from poor epilepsy control in later life and are dependent on care-givers for daily living. There is no previous study evaluating the Quality of Life (QOL) in children suffered from WS. METHOD A prospective cohort study was performed at six years in a group of children with West syndrome, followed up in the Sri Lanka Infantile Spasm Study (SLISS). The quality of life was evaluated using Sri Lankan Health-Related Quality-of-Life Index for school children (SLHRQ-S), an age-specific, primary caregiver proxy-rated, validated questionnaire for Sri Lankan children with epilepsy. Information on epilepsy, medication, and daily activities was obtained from the parents. RESULTS Fifty parents of initial 97 children treated for WS participated. The majority had no ongoing epilepsy (56%) at time of evaluation. The mean QOL was 67.22 (SD 15.68). Mean QOL scores for individual domains showed that physical domain was the worst affected (58.51 (SD = 22.11)). Psychological and social function domains were 68.73 (SD = 17.74) and 75.2 (SD = 14.87), respectively. Male sex (0.02), using multiple anti-seizure medications (0.00) and lower ILAE epilepsy control scale (0.02) were significantly associated with a poor quality of life. Age at onset, delay in treatment, and early spasm control were among the factors that did not influence quality of life. CONCLUSION Despite having control of their epilepsy in the majority, these children suffered from poor quality of life. The greater impact on the physical domain possibly is related to the effect of underlying pathologies.
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Affiliation(s)
| | - Carukshi Arambepola
- Department of Community Medicine, Faculty of Medicine, University of Colombo, Sri Lanka.
| | - Roshini Murugupillai
- Department of Clinical Sciences, Faculty of Health-care Sciences, Eastern University, Sri Lanka
| | | | - Ashan Jayawickrama
- Department of Paediatrics, Faculty of Medicine, University of Colombo, Sri Lanka
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Wanigasinghe J, Arambepola C, Ranganathan SS, Jayasundara K, Weerasinghe A, Wickramarachchi P. Epilepsy Outcome at Four Years in a Randomized Clinical Trial Comparing Oral Prednisolone and Intramuscular ACTH in West Syndrome. Pediatr Neurol 2021; 119:22-26. [PMID: 33836476 DOI: 10.1016/j.pediatrneurol.2021.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 01/01/2021] [Accepted: 01/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND This article explores the role of initial treatment on control of spasms and other epilepsies at four years in children previously treated for West syndrome. METHODS The Sri Lanka Infantile Spasm Study is a prospective clinical trial evaluating response to intra-muscular adrenocorticotropic hormone (ACTH) versus oral prednisolone. A previous report documented response through age 12 months. This article provides four-year follow-up data. RESULTS At age four years, 65 of the original 97 were available for follow-up; another 13 had died, and 19 moved and could not be contacted. Of the 65 children, 37 (57%) continued to have seizures and 28 were seizure free. In the 37 children with ongoing epilepsy, 32.4% continued to have spasms, either alone or in combination with other seizure types. The epilepsy types seen in these children were focal epilepsy (59.4%), mixed focal and generalized epilepsy (24%), generalized epilepsy only (10.8%), and uncertain (5%). The majority of those still having epilepsy (66.7%) were controlled on medication. There was no significant difference in the rate of epilepsy or spasms or their control by medication between those treated with ACTH or oral prednisolone. Spasm control at day 14 did not influence the four-year spasm or epilepsy outcome. CONCLUSIONS A majority of children diagnosed with West syndrome continued to have seizures at age four years, although most were controlled on antiseizure medication. The long-term risk of developing epilepsy or its control was the same, regardless of whether ACTH or prednisolone was initially used as treatment.
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Affiliation(s)
- Jithangi Wanigasinghe
- Faculty of Medicine, Department of Paediatrics, University of Colombo, Colombo, Sri Lanka.
| | - Carukshi Arambepola
- Faculty of Medicine, Department of Community Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - Kasun Jayasundara
- University Paediatric Unit, Lady Ridgeway Hospital, Colombo, Sri Lanka
| | - Ashangi Weerasinghe
- Faculty of Medicine, Department of Paediatrics, University of Colombo, Colombo, Sri Lanka
| | - Piyumi Wickramarachchi
- Faculty of Medicine, Department of Paediatrics, University of Colombo, Colombo, Sri Lanka
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Sumanasena SP, Wanigasinghe J, Arambepola C, Sri Ranganathan S, Muhandiram E. Effect of intramuscular ACTH versus oral prednisolone on the developmental trajectories of children with West syndrome over 24 months: A randomised control study. Eur J Paediatr Neurol 2021; 32:98-105. [PMID: 33894665 DOI: 10.1016/j.ejpn.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 04/02/2021] [Accepted: 04/03/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the developmental progression and compare the developmental attainments of children treated with two hormonal therapies for infantile spasms (IS) over two years (seizure and EEG outcomes of this RCT published previously). METHODS Newly diagnosed infants with IS were randomised to receive adrenocorticotrophin (ACTH) or prednisolone for 14 days. All underwent Bayley III Infant and Toddler Assessments in cognitive (Cog), receptive (RC) and expressive (EC) communication, fine (FM) and gross (GM) motor developmental subsets at baseline (T0), one-year (T1) and two-years (T2). RESULTS 95 infants randomised to prednisolone (n = 48) and ACTH (n = 47) groups were eligible for developmental assessments. Mean age at initial assessment was 8.75 months (SD = 6.37, range 1.46-34.4 months). 48 children presented for all three assessments. Mean composite scores of each developmental domain improved across the three time points; but the progression was significant only in relation to motor development (p = 0.04). When comparing the treatment outcomes at 2-years, mean composite scores of children treated with ACTH were significantly lower in motor domain (p = 0.023). As for developmental delay, the ACTH group (n = 32) showed significant delay in expressive communication (adjusted OR 5.46, 95% CI: 1.1, 28.57; p = 0.04) and fine motor (adjusted OR 9.4, 95% CI: 1.1, 83.3; p = 0.04) at T2 compared to the prednisolone (n = 30) in a regression analysis. CONCLUSION The number of children with delay at the 2 year follow up were significantly higher in two domains in the ACTH group compared to the prednisolone group. Overall results do not show a significant advantage of ACTH over prednisolone for developmental outcomes at two years, but further comparative studies over longer periods are required for more definitive conclusions.
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Affiliation(s)
- Samanmali P Sumanasena
- Paediatric Disabilities and Consultant Paediatrician, Postal address Department of Disability Studies Faculty of Medicine University of Kelaniya, P.O. Box 6, Thalagolla Road, Ragama Sri Lanka.
| | - Jithangi Wanigasinghe
- Paediatrics and Specialist Pediatric Neurologist, Postal address Department of Paediatrics Faculty of Medicine University of Colombo, No. 25, Kynsey Road, Colombo 08, Sri Lanka.
| | - Carukshi Arambepola
- Community Medicine and Specialist in Community Medicine, Postal address Department of Community Medicine Faculty of Medicine University of Colombo, No. 25, Kynsey Road, Colombo 08, Sri Lanka.
| | - Shalini Sri Ranganathan
- Pharmacology and Specialist in Paediatrics, Department of Pharmacology, Faculty of Medicine University of Colombo, No. 25, Kynsey Road, Colombo 08, Sri Lanka.
| | - Eindrini Muhandiram
- Department of Paediatrics, Faculty of Medicine University of Colombo, No. 25, Kynsey Road, Colombo 08, Sri Lanka.
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Gehlawat VK, Arya V, Bhardwaj H, Vaswani ND, Kaushik JS. Clinical profile of children with West syndrome: A retrospective chart review. J Family Med Prim Care 2021; 10:350-353. [PMID: 34017752 PMCID: PMC8132827 DOI: 10.4103/jfmpc.jfmpc_1405_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/17/2020] [Accepted: 10/02/2020] [Indexed: 11/23/2022] Open
Abstract
Background: This study was intended to document the clinical profile and treatment outcome of West syndrome in children attending a tertiary care centre in Northern India. Methods: Data were collected by a retrospective chart review of children diagnosed with West syndrome between January 2017 to January 2018. Information was recorded pertaining to the age at onset and presentation, etiology, and associated co-morbidities; results of electroencephalography (EEG) and neuroimaging; treatment given; and final outcome. The following drugs were used for treatment: ACTH (n = 7), prednisolone (n = 17), vigabatrin (n = 25), sodium valproate (n = 28), clonazepam (n = 30), and levetiracetam (n = 13) and modified Atkins diet (n = 7). The response was categorized as spasm cessation, partial improvement (>50% improvement), or no improvement. Results: Records of 30 children (21 boys) were analyzed. The median (IQR) age at onset was 4 (3, 6.5) months. The median (IQR) lag time to treatment was 5 (2,14) months. Eight (26%) were premature, 2 (7%) were small for gestational age, birth asphyxia in 56%, neonatal encephalopathy in 62%. EEG findings were hypsarrhythmia in 13 (43.3%) children and modified hypsarrhythmia in 9 (30%) children. MRI finding was periventricular leukomalacia (54.1%), cystic encephalomalacia (13.8%), normal MRI (20.7%) and one had arrested hydrocephalus. There was no improvement with valproate (93%), clonazepam (89%), levetiracetam (78%). Cessation of spasm was achieved with vigabatrin (28%), prednisolone (38.2%), ACTH (42.8%). Hypsarrhythmia resolved with improvement in of background and other epileptiform abnormalities in 17 children. Conclusion: The present research highlights favourable response of West syndrome to oral steroids, vigabatrin and ACTH with limited role of conventional antiepileptic drugs like sodium valporate, levetiracetam and clonazepam. Primary care physician plays a vital role in early recognition and treatment of epileptic spasm.
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Affiliation(s)
| | - Vandana Arya
- Department of Pediatrics, Pt. BD Sharma PGIMS, Rohtak, Haryana, India
| | - Harish Bhardwaj
- Consultant Pediatrician, Noble Heart Multispeciality Hospital, Rohtak, Haryana, India
| | - Narain D Vaswani
- Department of Pediatrics, Pt. BD Sharma PGIMS, Rohtak, Haryana, India
| | - Jaya S Kaushik
- Department of Pediatrics, Pt. BD Sharma PGIMS, Rohtak, Haryana, India
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Abstract
Over the last several decades, significant progress has been made in the discovery of appropriate therapy in the management of infantile spasms (IS). Based on several well-controlled studies, the American Academy of Neurology and the Child Neurology Society have published the current best practice parameters for the treatment of IS. However, dissemination and implementation of evidence-based guidelines remain a significant challenge. Though the number of well-performed controlled trials and systematic reviews is increasing exponentially, the proportion of valuable new information subsequently embedding into the routine clinical care is significantly lower. Planned and systematic implementation of evidence-based interventions in a given health care structure may outstrip the benefits of discovering a new insight, procedure, or drug in another controlled setting. Implementation problems can be broad-ranging to hinder effective, efficient, safe, timely, and patient-centered care without significant variation. The first part of this review article provides a detailed summary of some crucial comparative treatment studies of IS available in the literature. In the second part, practical challenges to mitigate the gap between knowledge and practice to improve outcomes in the management of IS has been explored, and a consolidated framework approach for systematic implementation research methodology has been discussed to implement evidence-based guidelines for the management of IS. Although large multicenter controlled studies will help gather quality evidence in the treatment of IS, a more comprehensive range of scientific methodologies, including qualitative research and mixed research methodologies, will hold the more considerable promise for implementing evidence-based practices in the health care system.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Section, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
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Madaan P, Chand P, Linn K, Wanigasinghe J, Lhamu Mynak M, Poudel P, Riikonen R, Kumar A, Dhir P, Negi S, Sahu JK. Management practices for West syndrome in South Asia: A survey study and meta-analysis. Epilepsia Open 2020; 5:461-474. [PMID: 32913954 PMCID: PMC7469760 DOI: 10.1002/epi4.12419] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/24/2020] [Accepted: 07/08/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Considering the dearth of literature on West syndrome (WS) from South Asian countries, this study aimed to evaluate the management practices in South Asia by an online survey and meta-analysis. METHODS An online questionnaire was sent to 223 pediatric neurologists/pediatricians in India, Pakistan, Myanmar, Sri Lanka, Bhutan, Nepal, and Bangladesh. Their responses were evaluated and supplemented by a meta-analysis. RESULTS Of 125 responses received (response rate: 56%), around 60% of responders observed male preponderance and an approximate lead-time-to-treatment (LTTT) of 4-12 weeks. The commonest etiology observed was a static structural insult (88.6% of responders). Most commonly used first-line drug (country-wise) was as follows: India-adrenocorticotropin hormone (ACTH, 50%); Pakistan-oral steroids (45.5%); Myanmar, Sri Lanka, and Nepal-oral steroids (94.4%); Bangladesh-ACTH (2/2); Bhutan-vigabatrin (3/5). ACTH and vigabatrin are not available in Myanmar and Nepal. The most commonly used regime for ACTH was maximal-dose-at-initiation-regime in India, Sri Lanka, and Bangladesh and gradually escalating-regime in Pakistan. Maximum dose of prednisolone was variable-most common response from India: 3-4 mg/kg/d; Pakistan, Bhutan, and Bangladesh: 2 mg/kg/d; Sri Lanka, Nepal, and Myanmar: 5-8 mg/kg/d or 60 mg/d. The total duration of hormonal therapy (including tapering) ranged from 4 to 12 weeks (67/91). Most responders considered cessation of spasms for four weeks as complete response (54/111) and advised electroencephalography (EEG; 104/123) to check for hypsarrhythmia resolution. Difficult access to pediatric EEG in Bhutan and Nepal is concerning. More than 95% of responders felt a need for more awareness. The meta-analysis supported the preponderance of male gender (68%; confidence interval [CI]: 64%-73%), structural etiology(80%; CI 73%-86%), longer LTTT (2.4 months; CI 2.1-2.6 months), and low response rate to hormonal therapy(18% and 28% for ACTH and oral steroids respectively) in WS in South Asia. SIGNIFICANCE This study highlights the practices and challenges in the management of WS in South Asia. These include a preponderance of male gender and structural etiology, a longer LTTT, difficult access to pediatric EEG, nonavailability of ACTH and vigabatrin in some countries, and low effectiveness of hormonal therapy in this region.
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Affiliation(s)
- Priyanka Madaan
- Pediatric Neurology UnitDepartment of PediatricsPostgraduate Institute of Medical Education and ResearchChandigarhIndia
| | | | - Kyaw Linn
- Pediatric Neurology UnitYangon Children HospitalYangonMyanmar
| | | | - Mimi Lhamu Mynak
- Department of PediatricsJigme Dorji Wangchuck National Referral HospitalThimphuBhutan
| | - Prakash Poudel
- Department of PediatricsB.P. Koirala Institute of Health SciencesDharanNepal
| | - Raili Riikonen
- Child NeurologyChildren's HospitalUniversity of Eastern Finland and Kuopio University HospitalKuopioFinland
| | - Amit Kumar
- Department of NeurologyAll India Institute of Medical SciencesNew DelhiIndia
| | - Pooja Dhir
- Pediatric Neurology UnitDepartment of PediatricsPostgraduate Institute of Medical Education and ResearchChandigarhIndia
| | - Sandeep Negi
- Pediatric Neurology UnitDepartment of PediatricsPostgraduate Institute of Medical Education and ResearchChandigarhIndia
| | - Jitendra Kumar Sahu
- Pediatric Neurology UnitDepartment of PediatricsPostgraduate Institute of Medical Education and ResearchChandigarhIndia
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Li S, Zhong X, Hong S, Li T, Jiang L. Prednisolone/prednisone as adrenocorticotropic hormone alternative for infantile spasms: a meta-analysis of randomized controlled trials. Dev Med Child Neurol 2020; 62:575-580. [PMID: 31903560 DOI: 10.1111/dmcn.14452] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2019] [Indexed: 11/27/2022]
Abstract
AIM To compare the efficacy and safety of prednisolone/prednisone and adrenocorticotropic hormone (ACTH) in the treatment of infantile spasms using a meta-analysis of randomized controlled trials (RCTs). METHOD In a systematic literature search of electronic databases (MEDLINE, Embase, the Cochrane Library), we identified RCTs that assessed prednisolone/prednisone compared with ACTH/tetracosactide in patients with infantile spasms. The electroclinical response and adverse events were evaluated. RESULTS Six RCTs (616 participants) were included in the meta-analysis. Compared with prednisolone/prednisone, ACTH/tetracosactide was not superior in terms of cessation of spasms at day 14 (relative risk 1.19, 95% confidence interval [CI] 0.74-1.92), day 42 (relative risk 1.02, 95% CI 0.63-1.65), and resolution of hypsarrhythmia on electroencephalogram (relative risk 1.14, 95% CI 0.71-1.81); the incidences of common adverse reactions caused by ACTH/tetracosactide were not lower than that of prednisolone/prednisone for irritability (relative risk 0.79, 95% CI 0.57-1.10), increased appetite (relative risk 0.78, 95% CI 0.57-1.08), weight gain (relative risk 0.86, 95% CI 0.56-1.32), and gastrointestinal upset (relative risk 0.60, 95% CI 0.35-1.02), though it seemed less frequent. INTERPRETATION Prednisolone/prednisone elicits a similar electroclinical response as ACTH for infantile spasms, which indicates that it can be an alternative to ACTH for treating infantile spasms. What this paper adds Prednisolone/prednisone is as effective as adrenocorticotropic hormone (ACTH) in electroclinical response of infantile spasms. Prednisolone/prednisone and ACTH cause similar and tolerable adverse effects, whose incidences are comparable. High-dose prednisone/prednisolone might be preferable to low dose for achieving freedom from spasms.
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Affiliation(s)
- Shaojun Li
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders (Chongqing), Children's Hospital of Chongqing Medical University, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Paediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xuefei Zhong
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders (Chongqing), Children's Hospital of Chongqing Medical University, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Paediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Electroneurophysiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Siqi Hong
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders (Chongqing), Children's Hospital of Chongqing Medical University, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Paediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Tingsong Li
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders (Chongqing), Children's Hospital of Chongqing Medical University, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Paediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Li Jiang
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders (Chongqing), Children's Hospital of Chongqing Medical University, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Paediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China
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11
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Chang YH, Chen C, Chen SH, Shen YC, Kuo YT. Effectiveness of corticosteroids versus adrenocorticotropic hormone for infantile spasms: a systematic review and meta-analysis. Ann Clin Transl Neurol 2019; 6:2270-2281. [PMID: 31657133 PMCID: PMC6856611 DOI: 10.1002/acn3.50922] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 09/22/2019] [Accepted: 09/23/2019] [Indexed: 01/26/2023] Open
Abstract
Objective To compare the therapeutic effectiveness of oral corticosteroids with that of adrenocorticotrophic hormone for infantile spasms. Methods PubMed, Embase, Scopus, and the Cochrane library were searched to retrieve studies published before December 2018 to identify pediatric patients with a diagnosis of infantile spasms. The interventions of oral corticosteroids and adrenocorticotrophic hormone were compared. We included only randomized controlled trials that reported the cessation of spasms as treatment response. The primary outcome was clinical spasm cessation on day 13 or 14. The secondary outcomes were the resolution of hypsarrhythmia, side effects, continued spasm control, spasm relapse rate, and subsequent epilepsy rate. Following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses, the study‐level quality assessment was conducted using the Cochrane risk‐of‐bias tool. Results After extensive review, 39 articles were included for meticulous evaluation. Five randomized controlled trials with a total of 239 individuals were eligible for further analysis. No significant difference was detected between the corticosteroids and adrenocorticotrophic hormone in the cessation of clinical spasms (odds ratio [OR]: 0.54; 95% confidence interval [CI]: 0.16 to 1.81; P = 0.32). The subgroups of high‐dose prednisolone versus adrenocorticotrophic hormone and low‐dose prednisone versus adrenocorticotrophic hormone also exhibited no significant difference. Furthermore, the two subgroups did not differ in terms of hypsarrhythmia resolution, side effects, relapse rate, or subsequent epilepsy rate. Interpretation This meta‐analysis suggests that high‐dose prednisolone is not inferior to adrenocorticotrophic hormone and that it be considered a safe and effective alternative treatment.
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Affiliation(s)
- Yin-Hsi Chang
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chiehfeng Chen
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
| | - Shu-Huey Chen
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, Shuang Ho Hospital, Ministry of Health and Welfare, Taipei Medical University, New Taipei City, Taiwan.,Taipei Cancer Center, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chun Shen
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yung-Ting Kuo
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, Shuang Ho Hospital, Ministry of Health and Welfare, Taipei Medical University, New Taipei City, Taiwan
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12
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Very-High-Dose Prednisolone Before ACTH for Treatment of Infantile Spasms: Evaluation of a Standardized Protocol. Pediatr Neurol 2019; 99:16-22. [PMID: 31331669 DOI: 10.1016/j.pediatrneurol.2019.06.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is ongoing debate regarding the comparative effectiveness of adrenocorticotropic hormone and prednisolone in the treatment of infantile spasms. With a large cohort and extended follow-up, we set out to evaluate a protocol in which adrenocorticotropic hormone is reserved for prednisolone nonresponders. METHODS The following standardized hormonal therapy protocol was adopted. Patients initially receive prednisolone (8 mg/kg/day [maximum 60 mg/day], divided in three daily doses for 14 days). Prednisolone responders taper it over 14 days, whereas prednisolone nonresponders immediately transition to natural adrenocorticotropic hormone (150 U/m2/day, divided in two daily doses for 14 days). We evaluated short-term response, defined as video-electroenecphaloagraphy-confirmed resolution of both epileptic spasms and hypsarrhythmia on day 14, without relapse for 28 additional days. We then evaluated long-term relapse and calculated the rates of sustained response at six, 12, and 18 months. RESULTS We identified 102 children with infantile spasms who were treated with prednisolone. Prior exposure to hormonal therapy and vigabatrin was observed among 12% and 35% of patients, respectively. Sixty (59%) patients responded to prednisolone, and 13 (33%) prednisolone nonresponders then responded to adrenocorticotropic hormone. Cumulative response to prednisolone and adrenocorticotropic hormone (if needed) was higher among treatment-naive patients (84%) than among patients with prior exposure to first-line treatment (51%), with P < 0.001. Relapse was relatively common among all subgroups. CONCLUSION Short-term response to prednisolone was favorable and higher among treatment-naive patients. These data suggest that prednisolone is a reasonable approach to initial therapy and that adrenocorticotropic hormone exhibits substantial efficacy after prednisolone failure.
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13
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Yoon DH, Moon JU, Lee JY, Lee IG. Reconsideration of Vigabatrin Effect in Infantile Spasms Treatment. ANNALS OF CHILD NEUROLOGY 2019. [DOI: 10.26815/acn.2019.00094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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14
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Abstract
West syndrome (WS), also known as infantile spasms, occurs in infancy with a peak between 4 and 7 months. Spasms, neurodevelopmental regression and hypsarrhythmia on electroencephalogram (EEG) basically define WS. The International League Against Epilepsy commission classifies the aetiologies of WS into genetic, structural, metabolic and unknown. Early diagnosis and a shorter lag time to treatment are essential for the overall outcome of WS patients. These goals are feasible with the addition of brain magnetic resonance imaging (MRI) and genetic and metabolic testing. The present work analysed the medical literature on WS and reports the principal therapeutic protocols of its management. Adrenocorticotropic hormone (ACTH), vigabatrin (VGB) and corticosteroids are the first-line treatments for WS. There is no unique therapeutic protocol for ACTH, but most of the evidence suggests that low doses are as effective as high doses for short-term treatment, which is generally 2 weeks followed by dose tapering. VGB is generally administered at doses from 50 to 150 mg/kg/day, but its related retinal toxicity, which occurs in 21-34% of infants, is most frequently observed when treatment periods last longer than 6 months. Among corticosteroids, a treatment of 14 days of oral prednisolone (40-60 mg/day) has been considered effective and well tolerated. Considering that an early diagnosis and a shorter lag time to treatment are essential for successful outcomes in these patients, further studies on efficacy of the different therapeutic approaches with evaluation of final outcome after cessation of therapy are needed.
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15
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Raga SV, Wilmshurst JM. Epileptic spasms: Evidence for oral corticosteroids and implications for low and middle income countries. Seizure 2018; 59:90-98. [DOI: 10.1016/j.seizure.2018.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/07/2018] [Accepted: 05/11/2018] [Indexed: 12/22/2022] Open
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16
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Wanigasinghe J, Arambepola C, Ranganathan SS, Sumanasena S. Randomized, Single-Blind, Parallel Clinical Trial on Efficacy of Oral Prednisolone Versus Intramuscular Corticotropin: A 12-Month Assessment of Spasm Control in West Syndrome. Pediatr Neurol 2017; 76:14-19. [PMID: 28927673 DOI: 10.1016/j.pediatrneurol.2017.07.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 07/09/2017] [Accepted: 07/11/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We earlier completed a single-blind, parallel-group, randomized clinical trial to test the null hypothesis that adrenocorticotropic hormone (ACTH) is not superior to high-dose prednisolone for short-term control of West syndrome. We now present long-term follow-up data for spasm control for individuals who completed this earlier trial. METHODS Infants with untreated West syndrome were randomized to receive 14 days of prednisolone (40 to 60 mg/day) or intramuscular long-acting ACTH (40 to 60 IU every other day). They were evaluated at three, six, and 12 months to evaluate long-term spasm control. RESULTS The total number of infants treated was 97 (48 prednisolone; 49 ACTH). All completed the treatment course. Eighty-five, 82, and 76 children were available for follow-up at three, six, and 12 months. The number lost to follow-up at each interval was not statistically different. Likelihood of spasm freedom at three months was significantly higher for prednisolone (64.6%) than for ACTH (38.8%) (P = 0.01; odds ratio = 2.9; 95% confidence interval = 1.3 to 6.6). At six months (P = 0.19) and twelve months (P = 0.13), the control of spasms was not statistically different, although a trend in favor of prednisolone was documented at both of these time points (58.3% versus 44.9% for ACTH at six months and 56.2% versus 40.8% with ACTH at 12 months). After initial remission by day 14 (n = 46), the likelihood of a relapse within the next 12 months was not statistically different between the two treatment groups (P = 0.1). CONCLUSIONS Control of spasms at three months was significantly better if initially treated with prednisolone. Control of spasms at six and 12 months was not significantly different despite a trend favoring prednisolone. Risk of relapse following initial remission was similar in the two groups.
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Affiliation(s)
| | - Carukshi Arambepola
- Department of Community Medicine, Faculty of Medicine, University of Colombo, Sri Lanka
| | | | - Samanmali Sumanasena
- Department of Disability Studies, Faculty of Medicine, University of Kelaniya, Sri Lanka
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17
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Wanigsinghe J, Arambepola C. Letter Reply. Pediatr Neurol 2017; 74:e1. [PMID: 28688788 DOI: 10.1016/j.pediatrneurol.2016.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Short-Term Outcome of Intravenous Methylprednisolone Pulse Therapy in Patients With Infantile Spasms. Pediatr Neurol 2017; 71:50-55. [PMID: 28483397 DOI: 10.1016/j.pediatrneurol.2017.03.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 03/24/2017] [Accepted: 03/27/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many studies advocate hormonal treatments including high-dose oral prednisolone as an effective treatment for epileptic spasms. However, little is known about the effects of intravenous methylprednisolone pulse therapy on infantile spasms. We investigated the short-term response to intravenous methylprednisolone pulse therapy for the treatment of infantile spasms. METHODS Patients with newly diagnosed infantile spasms and hypsarrhythmia on electroencephalography (EEG) at two tertiary centers in Korea were included. Patients received intravenous infusions of 30 mg/kg/day methylprednisolone for three days with tapering doses of oral prednisolone for two to four weeks for the treatment of infantile spasms. Response to methylprednisolone pulse therapy was evaluated by seizure frequency and follow-up EEG within three weeks. RESULTS Fourteen patients were sudied. The mean age at the onset of spasms was 7.0 months (range, 2.0 to 11.0 months). Etiological factors included structural abnormalities (N = 11), chromosomal anomaly (N = 1), and unknown (N = 2). Nine of 14 participants (64.3%) demonstrated complete freedom from spasm and resolution of hypsarrhythmia on EEG within 3 weeks; however, only five of nine responders (55.5%) remained free of spasms after the discontinuation of oral steroids. Adverse effects, including irritability or infection, were observed in four patients but were tolerable in all. CONCLUSIONS Short-term methylprednisolone pulse therapy for the treatment of infantile spasms or hypsarrhythmia demonstrated rapid improvement in EEG and cessation of spasms without serious adverse effects. Further studies are needed to determine the long-term effects of spasm control.
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19
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Abstract
OBJECTIVES West syndrome (also known as infantile spasm because of its main seizure type) is a rare form of epilepsy that begins during early infancy. Recent guidelines and reviews on West syndrome recommend the use of adrenocorticotropic hormone steroids, or vigabatrin, as the first-line treatment. However, West syndrome remains to be one of the most challenging epilepsies to treat. Here, we systematically reviewed the current literature obtained during the previous decade. This article provides an overview of the current treatment of infantile spasms. METHODS PubMed and EMBASE were searched to retrieve studies on human published during 2005-2015 and to identify patients with clinical diagnosis of infantile spasms. Drug or diet treatments were used as interventions and comparators. RESULTS We included 55 studies, of which 1 study was a meta-analysis, 9 were randomized controlled trials, 21 were prospective studies, and 24 were retrospective studies. Topiramate, levetiracetam, zonisamide, and sodium valproate with benzodiazepine (clonazepam or nitrazepam) were found to be potential drugs for treating West syndrome besides adrenocorticotropic hormone, steroids, and vigabatrin. Ketogenic diet and modified Atkins diet were also found to be effective. CONCLUSIONS To date, data regarding the efficacy of treatments of West syndrome still remain limited. Some treatments, including topiramate and ketogenic diet, seem promising besides adrenocorticotropic hormone, steroids, and vigabatrin. Well-designed trials are warranted to validate the findings.
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20
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Tiwari L, Kumar M. Oral Prednisolone Versus Intramuscular Corticotropin in West Syndrome. Pediatr Neurol 2016; 64:e7. [PMID: 26857521 DOI: 10.1016/j.pediatrneurol.2016.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 01/06/2016] [Accepted: 01/09/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Lokesh Tiwari
- Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar, India.
| | - Manish Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar, India
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21
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Abstract
Infantile spasms, and specifically within the context of West syndrome , is one of the most common epileptic encephalopathies to occur in early infancy. Early recognition and treatment can improve neurodevelopmental outcome in some cases, although the underlying aetiology is probably the most important prognostic factor in both spasm suppression and developmental outcome. Corticosteroids, either adrenocorticotrophic hormone (ACTH) or prednisolone, and vigabatrin are currently the preferred first-line treatment options. Vigabatrin is the treatment of choice when the underlying cause is tuberous sclerosis complex (TSC). Emerging evidence suggests that a combination of steroid and vigabatrin may be more effective in the suppression of spasms and resolution of hypsarrhythmia, the electro-encephalographic signal of spasms. Several other anti-epileptic drugs (AEDs) (levetiracetam, nitrazepam, sodium valproate, topiramate, zonisamide) are usually used as add-on or adjunctive treatment in refractory cases. Pyridoxine (or pyridoxal phosphate) and the ketogenic diet are established treatment options in refractory cases. There is some evidence that neuro-active steroids, including ganaxolone, may be effective; however, clinical trials undertaken intermittently for over a decade have yet to prove their efficacy, not only for the suppression of infantile spasms but also for the resolution of hypsarrhythmia, which may be as important as seizure control in developmental outcome in these children. Insights into developing novel treatment options have emerged from rodent models of infantile spasms, and research is continuing into the efficacy of rapamycin in improving outcomes in infantile spasms. This review provides a brief overview of the existing scientific literature around treatment options and outlines emerging newer treatment options in infantile spasms.
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Affiliation(s)
- Anand Iyer
- The Roald Dahl Department of Neurophysiology, Alder Hey in the Park Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.
| | - Richard Appleton
- The Roald Dahl Department of Neurophysiology, Alder Hey in the Park Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK
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22
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Roach ES. Applying the Lessons of Tuberous Sclerosis: The 2015 Hower Award Lecture. Pediatr Neurol 2016; 63:6-22. [PMID: 27543366 DOI: 10.1016/j.pediatrneurol.2016.07.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 07/07/2016] [Indexed: 12/15/2022]
Abstract
Tuberous sclerosis complex is a dominantly inherited disorder that variably affects the brain, skin, kidneys, heart, and other organs. Its neurological manifestations include epilepsy, autism, cognitive and behavioral dysfunction, and giant cell tumors. A mutation of either TSC1 or TSC2 can cause tuberous sclerosis complex. Their two gene products, hamartin and tuberin, form a physical complex which normally inhibits protein synthesis mediated through the mechanistic target of rapamycin, so a TSC1 or TSC2 mutation results in overactivation of the mechanistic target of rapamycin cascade. In addition to their tumor suppressor roles, TSC1 and TSC2 help to regulate cell size, neuronal migration, axon formation, and synaptic plasticity. Clinical trials of two different the mechanistic target of rapamycin inhibitors have demonstrated substantial improvement of tuberous sclerosis complex-related tumors, and a recent trial also showed a benefit from the mechanistic target of rapamycin inhibitor everolimus in the treatment of refractory epilepsy due to tuberous sclerosis complex. Effective mechanism-based therapy is now available for some manifestations of tuberous sclerosis complex.
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Affiliation(s)
- E Steve Roach
- Division of Child Neurology, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio.
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23
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Knupp KG, Coryell J, Nickels KC, Ryan N, Leister E, Loddenkemper T, Grinspan Z, Hartman AL, Kossoff EH, Gaillard WD, Mytinger JR, Joshi S, Shellhaas RA, Sullivan J, Dlugos D, Hamikawa L, Berg AT, Millichap J, Nordli DR, Wirrell E. Response to treatment in a prospective national infantile spasms cohort. Ann Neurol 2016; 79:475-84. [PMID: 26704170 DOI: 10.1002/ana.24594] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/23/2015] [Accepted: 12/23/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Infantile spasms are seizures associated with a severe epileptic encephalopathy presenting in the first 2 years of life, and optimal treatment continues to be debated. This study evaluates early and sustained response to initial treatments and addresses both clinical remission and electrographic resolution of hypsarrhythmia. Secondarily, it assesses whether response to treatment differs by etiology or developmental status. METHODS The National Infantile Spasms Consortium established a multicenter, prospective database enrolling infants with new diagnosis of infantile spasms. Children were considered responders if there was clinical remission and resolution of hypsarrhythmia that was sustained at 3 months after first treatment initiation. Standard treatments of adrenocorticotropic hormone (ACTH), oral corticosteroids, and vigabatrin were considered individually, and all other nonstandard therapies were analyzed collectively. Developmental status and etiology were assessed. We compared response rates by treatment group using chi-square tests and multivariate logistic regression models. RESULTS Two hundred thirty infants were enrolled from 22 centers. Overall, 46% of children receiving standard therapy responded, compared to only 9% who responded to nonstandard therapy (p < 0.001). Fifty-five percent of infants receiving ACTH as initial treatment responded, compared to 39% for oral corticosteroids, 36% for vigabatrin, and 9% for other (p < 0.001). Neither etiology nor development significantly modified the response pattern by treatment group. INTERPRETATION Response rate varies by treatment choice. Standard therapies should be considered as initial treatment for infantile spasms, including those with impaired development or known structural or genetic/metabolic etiology. ACTH appeared to be more effective than other standard therapies.
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Affiliation(s)
- Kelly G Knupp
- Departments of Pediatrics and Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jason Coryell
- Departments of Pediatrics and Neurology, School of Medicine, Oregon Health & Sciences University, Portland, OR
| | | | - Nicole Ryan
- Division of Neurology, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Erin Leister
- Colorado School of Public Health, Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA
| | | | - Adam L Hartman
- Departments of Neurology and Pediatrics, Johns Hopkins Hospital, Baltimore, MD
| | - Eric H Kossoff
- Departments of Neurology and Pediatrics, Johns Hopkins Hospital, Baltimore, MD
| | | | - John R Mytinger
- Department of Pediatrics, Division of Pediatric Neurology, Ohio State University, Nationwide Children's Hospital, Columbus, OH
| | - Sucheta Joshi
- Department of Pediatrics & Communicable Diseases (Division of Pediatric Neurology), University of Michigan, Ann Arbor, MI
| | - Renée A Shellhaas
- Department of Pediatrics & Communicable Diseases (Division of Pediatric Neurology), University of Michigan, Ann Arbor, MI
| | - Joseph Sullivan
- Departments of Pediatrics and Neurology, University of San Francisco, San Francisco, CA
| | - Dennis Dlugos
- Division of Neurology, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lorie Hamikawa
- Department of Neurology, University of Washington, Seattle, WA
| | - Anne T Berg
- Ann & Robert H. Lurie Children's Hospital of Chicago and Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - John Millichap
- Ann & Robert H. Lurie Children's Hospital of Chicago and Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Douglas R Nordli
- Ann & Robert H. Lurie Children's Hospital of Chicago and Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elaine Wirrell
- Departments of Neurology and Pediatrics, Mayo Clinic, Rochester, MN
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24
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Mytinger JR, Camfield PR. Synthetic ACTH Is Not Superior to Prednisolone for Infantile Spasms: Randomized Clinical Trials and Tribulations. Pediatr Neurol 2015; 53:181-2. [PMID: 26302697 DOI: 10.1016/j.pediatrneurol.2015.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- John R Mytinger
- Division of Pediatric Neurology, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio.
| | - Peter R Camfield
- Department of Pediatrics, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
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25
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Wanigasinghe J, Arambepola C, Sri Ranganathan S, Sumanasena S, Attanapola G. Randomized, Single-Blind, Parallel Clinical Trial on Efficacy of Oral Prednisolone Versus Intramuscular Corticotropin on Immediate and Continued Spasm Control in West Syndrome. Pediatr Neurol 2015. [PMID: 26216500 DOI: 10.1016/j.pediatrneurol.2015.05.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE A single-center, single-blind, parallel-group, randomized clinical trial was performed to test the null hypothesis that adrenocorticotropic hormone is not superior to high-dose prednisolone for treatment of newly diagnosed West syndrome. METHODS Newly diagnosed infants with West syndrome were randomized to receive 14 days of oral prednisolone (40-60 mg/day) or a synthetically prepared intramuscular long-acting adrenocorticotropic hormone (40-60 IU/every other day [0.5-0.75 mg]) according to the United Kingdom Infantile Spasm Study protocol. They were blindly evaluated for infantile spasm remission by day 14, electroclinical remission (spasm cessation + resolution of hypsarrhythmia on a 30-minute electroencephalograph) by day 14 and continued spasm freedom for 28 days. RESULTS Ninety-seven patients were enrolled in the study, with 48 of them receiving prednisolone and 49 receiving ACTH. There was no significant difference in the baseline characteristics or risk factors for the two treatment groups. By day 14, cessation of infantile spasms occurred in 28/48 (58.3%) infants on prednisolone compared with only 18/49 (36.7%) infants given adrenocorticotropic hormone (P = 0.03) and electroclinical remission in 21 on prednisolone compared with nine on adrenocorticotropic hormone (P = 0.007). Sustained spasm control for 28 consecutive days following electroclinical remission occurred in 15 children on prednisolone compared with six on adrenocorticotropic hormone (P = 0.008). The total number of days required for spasm cessation was significantly less in those treated with prednisolone (3.85 days ± 2.4) compared with adrenocorticotropic hormone (8.65 days ± 3.7) (P = 0.001). Among patients who did not achieve remission, there was a non-significant trend toward greater quantitative reduction of spasms with prednisolone than with adrenocorticotropic hormone (P = 0.079). CONCLUSION Synthetic adrenocorticotropic hormone of 40-60 IU/every other day did not yield superior rates of electroencephalographic or clinical remission when compared with prednisolone of 40-60 mg/day. Significantly, more patients achieved electroclinical remission when treated with prednisolone than with adrenocorticotropic hormone.
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Affiliation(s)
- Jithangi Wanigasinghe
- Department of Paediatrics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
| | - Carukshi Arambepola
- Department of Community Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - Samanmalie Sumanasena
- Department of Disability Studies, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | - Gangani Attanapola
- Department of Paediatrics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Nunes CA, Alvarenga VO, de Souza Sant'Ana A, Santos JS, Granato D. The use of statistical software in food science and technology: Advantages, limitations and misuses. Food Res Int 2015; 75:270-280. [DOI: 10.1016/j.foodres.2015.06.011] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 06/07/2015] [Accepted: 06/08/2015] [Indexed: 12/22/2022]
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Wilmshurst JM, Gaillard WD, Vinayan KP, Tsuchida TN, Plouin P, Van Bogaert P, Carrizosa J, Elia M, Craiu D, Jovic NJ, Nordli D, Hirtz D, Wong V, Glauser T, Mizrahi EM, Cross JH. Summary of recommendations for the management of infantile seizures: Task Force Report for the ILAE Commission of Pediatrics. Epilepsia 2015; 56:1185-97. [PMID: 26122601 DOI: 10.1111/epi.13057] [Citation(s) in RCA: 241] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2015] [Indexed: 11/29/2022]
Abstract
Evidence-based guidelines, or recommendations, for the management of infants with seizures are lacking. A Task Force of the Commission of Pediatrics developed a consensus document addressing diagnostic markers, management interventions, and outcome measures for infants with seizures. Levels of evidence to support recommendations and statements were assessed using the American Academy of Neurology Guidelines and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The report contains recommendations for different levels of care, noting which would be regarded as standard care, compared to optimal care, or "state of the art" interventions. The incidence of epilepsy in the infantile period is the highest of all age groups (strong evidence), with epileptic spasms the largest single subgroup and, in the first 2 years of life, febrile seizures are the most commonly occurring seizures. Acute intervention at the time of a febrile seizure does not alter the risk for subsequent epilepsy (class 1 evidence). The use of antipyretic agents does not alter the recurrence rate (class 1 evidence), and there is no evidence to support initiation of regular antiepileptic drugs for simple febrile seizures (class 1 evidence). Infants with abnormal movements whose routine electroencephalography (EEG) study is not diagnostic, would benefit from video-EEG analysis, or home video to capture events (expert opinion, level U recommendation). Neuroimaging is recommended at all levels of care for infants presenting with epilepsy, with magnetic resonance imaging (MRI) recommended as the standard investigation at tertiary level (level A recommendation). Genetic screening should not be undertaken at primary or secondary level care (expert opinion). Standard care should permit genetic counseling by trained personal at all levels of care (expert opinion). Genetic evaluation for Dravet syndrome, and other infantile-onset epileptic encephalopathies, should be available in tertiary care (weak evidence, level C recommendation). Patients should be referred from primary or secondary to tertiary level care after failure of one antiepileptic drug (standard care) and optimal care equates to referral of all infants after presentation with a seizure (expert opinion, level U evidence). Infants with recurrent seizures warrant urgent assessment for initiation of antiepileptic drugs (expert opinion, level U recommendation). Infantile encephalopathies should have rapid introduction and increment of antiepileptic drug dosage (expert opinion, level U recommendation). There is no high level evidence to support any particular current agents for use in infants with seizures. For focal seizures, levetiracetam is effective (strong evidence); for generalized seizures, weak evidence supports levetiracetam, valproate, lamotrigine, topiramate, and clobazam; for Dravet syndrome, strong evidence supports that stiripentol is effective (in combination with valproate and clobazam), whereas weak evidence supports that topiramate, zonisamide, valproate, bromide, and the ketogenic diet are possibly effective; and for Ohtahara syndrome, there is weak evidence that most antiepileptic drugs are poorly effective. For epileptic spasms, clinical suspicion remains central to the diagnosis and is supported by EEG, which ideally is prolonged (level C recommendation). Adrenocorticotropic hormone (ACTH) is preferred for short-term control of epileptic spasms (level B recommendation), oral steroids are probably effective in short-term control of spasms (level C recommendation), and a shorter interval from the onset of spasms to treatment initiation may improve long-term neurodevelopmental outcome (level C recommendation). The ketogenic diet is the treatment of choice for epilepsy related to glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency (expert opinion, level U recommendation). The identification of patients as potential candidates for epilepsy surgery should be part of standard practice at primary and secondary level care. Tertiary care facilities with experience in epilepsy surgery should undertake the screening for epilepsy surgical candidates (level U recommendation). There is insufficient evidence to conclude if there is benefit from vagus nerve stimulation (level U recommendation). The key recommendations are summarized into an executive summary. The full report is available as Supporting Information. This report provides a comprehensive foundation of an approach to infants with seizures, while identifying where there are inadequate data to support recommended practice, and where further data collection is needed to address these deficits.
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Affiliation(s)
- Jo M Wilmshurst
- Paediatric Neurology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - William D Gaillard
- Pediatrics and Neurology, Division Epilepsy and Neurophysiology, Comprehensive Pediatric Epilepsy Program, George Washington University, Washington, District of Columbia, U.S.A
| | | | - Tammy N Tsuchida
- Department of Neurology, Children's National Medical Center, Washington, District of Columbia, U.S.A
| | - Perrine Plouin
- Clinical Neurophysiology Department, INSERM U663, Hospital for Sick Children, Paris, France
| | - Patrick Van Bogaert
- Paediatric Neurology, Department of Pediatrics, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jaime Carrizosa
- Pediatric Department Child Neurology Service, University of Antioquia, Medellín, Colombia
| | - Maurizio Elia
- Unit of Neurology and Clinical Neurophysiopathology, IRCCS Italy Oasi Institute for Research on Mental Retardation and Brain Aging, Troina, EN, Italy
| | - Dana Craiu
- Department of Neurology, Pediatric Neurology, Psychiatry, Neurosurgery, "Carol Davila" University of Medicine Bucharest, Bucharest, Romania.,"Alexandru Obregia" Clinical Hospital, Bucharest, Romania
| | - Nebojsa J Jovic
- Neurology, Clinic of Neurology and Psychiatry for Children and Youth, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Doug Nordli
- Epilepsy Center, Children's Memorial Hospital, Chicago, Illinois, U.S.A
| | - Deborah Hirtz
- Office of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Rockville, Maryland, U.S.A
| | - Virginia Wong
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong.,Division of Paediatric Neurology/Developmental Behavioural Paediatrics/NeuroHabilitation, Duchess of Kent Children Hospital, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Tracy Glauser
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Eli M Mizrahi
- Peter Kellaway Section of Neurophysiology, Department of Neurology, Baylor College of Medicine, Houston, Texas, U.S.A.,Section of Pediatric Neurology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, U.S.A
| | - J Helen Cross
- Childhood Epilepsy, Paediatric Neurology, UCL-Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, NHS Foundation Trust, London, United Kingdom
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Wilmshurst JM, Burman R, Gaillard WD, Cross JH. Treatment of infants with epilepsy: Common practices around the world. Epilepsia 2015; 56:1033-46. [DOI: 10.1111/epi.13003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 01/25/2023]
Affiliation(s)
- Jo M. Wilmshurst
- Department of Pediatric Neurology; Red Cross War Memorial Children's Hospital; University of Cape Town; Cape Town South Africa
| | - Richard Burman
- Department of Pediatric Neurology; Red Cross War Memorial Children's Hospital; University of Cape Town; Cape Town South Africa
| | - William D. Gaillard
- Center for Neuroscience, Children's National Medical Center; George Washington University; Washington District of Columbia U.S.A
| | - J. Helen Cross
- UCL-Institute of Child Health; Great Ormond Street Hospital for Children NHS Foundation Trust; London United Kingdom
- Young Epilepsy; Lingfield United Kingdom
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Millichap JG, Millichap JJ. Oral Prednisolone vs. IM Corticotropin and Hypsarrhythmia* in West Syndrome. Pediatr Neurol Briefs 2014. [DOI: 10.15844/pedneurbriefs-28-8-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Mytinger JR, Heyer GL. Oral corticosteroids versus adrenocorticotropic hormone for infantile spasms--an unfinished story. Pediatr Neurol 2014; 51:13-4. [PMID: 24938134 DOI: 10.1016/j.pediatrneurol.2014.05.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- John R Mytinger
- Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, College of Medicine, Columbus, Ohio.
| | - Geoffrey L Heyer
- Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, College of Medicine, Columbus, Ohio
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