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Stojanović NM, Rajković I, Raičević V, Petković MN, Randjelović PJ, Radulović NS. Lemon Balm ( Melissa officinalis) Essential Oil Moderately Affects Strychnine-Induced and Pentylenetetrazol-Induced Convulsions — In Silico and In Vivo Studies. Nat Prod Commun 2022. [DOI: 10.1177/1934578x221139961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Epileptic seizures are a consequence of uncontrolled neuronal discharge and demand urgent and prolonged treatment. Due to a lack of potent and low-risk drugs that could prevent seizures, efforts are underway to discover new drugs, and plant metabolites are often considered valuable candidates in this search. Lemon balm ( Melissa officinalis L., Lamiaceae) is a world-renowned medicinal plant affecting central nervous system function. In this study, we aimed to examine whether the results from in silico modeling of the interactions of major lemon balm essential oil constituents with GABAA and glycine receptors correspond to in vivo results of the convulsions in mice induced by the application of either pentylenetetrazol (GABAA antagonistic) or strychnine (glycine receptor antagonist). While molecular docking experiments of essential oil constituents to the two receptors demonstrated the possibility of ligand–receptor interactions, no binding poses were scored highly, and as the in vivo effect of the essential oil on convulsions seems to be only moderate, the results of the in silico study seem not to contradict results obtained by in vivo models. Thus, we can say that molecular docking might be a useful tool in initial screening for active constituents of natural product mixtures and the potential prediction of their activity in models in vivo.
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Affiliation(s)
| | | | - Vidak Raičević
- Department of Chemistry, Biochemistry and Environmental Protection, Faculty of Sciences, University of Novi Sad, Novi Sad, Serbia
| | - Milan N. Petković
- Department of Physiology, Faculty of Medicine, University of Niš, Niš, Serbia
| | | | - Niko S. Radulović
- Department of Chemistry, Faculty of Sciences and Mathematics, University of Niš, Niš, Serbia
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An inventory of European data sources to support pharmacoepidemiologic research on neurodevelopmental outcomes in children following medication exposure in pregnancy: A contribution from the ConcePTION project. PLoS One 2022; 17:e0275979. [PMID: 36240253 PMCID: PMC9565459 DOI: 10.1371/journal.pone.0275979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 09/27/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Studies on medication safety in pregnancy are increasingly focusing on child neurodevelopmental outcomes. Establishing neurodevelopmental safety is complex due to the range of neurodevelopmental outcomes and the length of follow-up needed for accurate assessment. The aim of this study was to provide an inventory of European data sources for use in pharmacoepidemiologic studies investigating neurodevelopment following maternal medication exposure. METHOD The EUROmediSAFE inventory of data sources in Europe for evaluating perinatal and long-term childhood risks associated with in-utero exposure to medication was updated by contacting colleagues across 31 European countries, literature review and internet searches. Included data sources must record at least one neurodevelopmental outcome and maternal medication use in pregnancy must be available, either in the data source itself or through linkage with another data source. Information on the domain of neurodevelopment, measure/scale used and the approach to measurement were recorded for each data source. RESULTS Ninety data sources were identified across 14 countries. The majority (63.3%) were created for health surveillance and research with the remaining serving administrative purposes (21.1% healthcare databases,15.6% other administrative databases). Five domains of neurodevelopment were identified-infant development (36 data sources,13 countries), child behaviour (27 data sources, 10 countries), cognition (29 data sources, 12 countries), educational achievement (20 data sources, 7 countries), and diagnostic codes for neurodevelopmental disorders (42 data sources, 11 countries). Thirty-nine data sources, in 12 countries, had information on more than one domain of neurodevelopment. CONCLUSION This inventory is invaluable to future studies planning to investigate the neurodevelopmental impact of medication exposures during pregnancy. Caution must be used when combining varied approaches to neurodevelopment outcome measurement, the age of children in the data source, and the sensitivity and specificity of the outcome measure selected should be borne in mind.
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Albaradie R, Habibullah H, Mir A, Alshammari AK, Alajmi MS, Alsubaie FA, Alsudairi RR, Bashir S. The prevalence of seizures in children with developmental delay. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2021; 26:186-191. [PMID: 33814372 PMCID: PMC8024126 DOI: 10.17712/nsj.2021.2.20200106] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/08/2021] [Indexed: 11/20/2022]
Abstract
Objectives: To study the prevalence of seizures in children with GDD and identify the characteristics of such patients; to examine the association of GDD with epilepsy and to determine the effect of certain risk factors on this association. Methods: A retrospective cross-sectional study conducted at the pediatric neurology and developmental assessment clinic at King Fahad specialist hospital (KFSH), Saudi Arabia. All data were collected by reviewing the electronic medical records of 200 pediatric patients who presented with global developmental delay from February 2016 to April 2018. Results: The sample includes 200 children (113 males, 87 females) aged zero to 12 years. The largest group of participants came from the Dammam region, representing 27.5% of the sample. The prevalence of epilepsy in GDD patients was 56%; the epilepsy and non-epilepsy groups differed significantly in age. The most common type of seizure was generalized onset motor, which were observed in 37.5% of the sample. Problems during labor occurred in 15% of the sample; consanguineous marriage occurred in 61.6% of the participants. Neither of these factors differed significantly in the epilepsy and non-epilepsy groups. Advanced paternal age did differ significantly in the two groups (p=0.003). Conclusion: The prevalence of epilepsy is high in children with GDD, and of the factors studied here, the most significant variables affecting this correlation are the type of seizure and advanced paternal age.
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Affiliation(s)
- Raidah Albaradie
- From the Department of Pediatric neurology (Albaradie, Habibullah, Mir), Neuroscience Center (Bashir), King Fahad Specialist Hospital, Dammam, from the College of Medicine (Alshammari, Alajmi, Alsubaie, Alsudairi), Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Hafiz Habibullah
- From the Department of Pediatric neurology (Albaradie, Habibullah, Mir), Neuroscience Center (Bashir), King Fahad Specialist Hospital, Dammam, from the College of Medicine (Alshammari, Alajmi, Alsubaie, Alsudairi), Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Ali Mir
- From the Department of Pediatric neurology (Albaradie, Habibullah, Mir), Neuroscience Center (Bashir), King Fahad Specialist Hospital, Dammam, from the College of Medicine (Alshammari, Alajmi, Alsubaie, Alsudairi), Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Alaa K Alshammari
- From the Department of Pediatric neurology (Albaradie, Habibullah, Mir), Neuroscience Center (Bashir), King Fahad Specialist Hospital, Dammam, from the College of Medicine (Alshammari, Alajmi, Alsubaie, Alsudairi), Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Modhi S Alajmi
- From the Department of Pediatric neurology (Albaradie, Habibullah, Mir), Neuroscience Center (Bashir), King Fahad Specialist Hospital, Dammam, from the College of Medicine (Alshammari, Alajmi, Alsubaie, Alsudairi), Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Fatima A Alsubaie
- From the Department of Pediatric neurology (Albaradie, Habibullah, Mir), Neuroscience Center (Bashir), King Fahad Specialist Hospital, Dammam, from the College of Medicine (Alshammari, Alajmi, Alsubaie, Alsudairi), Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Reem R Alsudairi
- From the Department of Pediatric neurology (Albaradie, Habibullah, Mir), Neuroscience Center (Bashir), King Fahad Specialist Hospital, Dammam, from the College of Medicine (Alshammari, Alajmi, Alsubaie, Alsudairi), Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Shahid Bashir
- From the Department of Pediatric neurology (Albaradie, Habibullah, Mir), Neuroscience Center (Bashir), King Fahad Specialist Hospital, Dammam, from the College of Medicine (Alshammari, Alajmi, Alsubaie, Alsudairi), Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
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Han SH, Lee H, Shin JY, Moon HJ, Lee SY. Real-world prescribing trends of valproate in women with epilepsy in Korea. Epilepsy Behav 2021; 115:107700. [PMID: 33421853 DOI: 10.1016/j.yebeh.2020.107700] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
Avoiding valproate is recommended in women of childbearing age due to possible teratogenicity and infertility. We aimed to examine the recent trend of valproate prescriptions in Korea to review the adequacy of anticonvulsant prescriptions in women with epilepsy (WWE). Oral valproate utilization was assessed using nationwide and unselected data from the Korean National Health Insurance Service from 2009 to 2017. The temporal trends of the proportions of valproate prescriptions were analyzed using the Poisson regression model and expressed as average annual percentage change (AAPC). Among the WWE of childbearing age, valproate was prescribed in 37.0% overall and 29.4% as initial prescription in 2017. The proportion of valproate utilization showed a decreasing trend in overall prescription (AAPC = -1.10%) and initial prescription (AAPC = -2.63%). However, the proportion was static over time in the initial monotherapy group (AAPC = -0. 53%), while it was significantly decreasing in the initial polytherapy group (AAPC = -8.25%). A noticeable proportion of WWE was still being prescribed valproate in Korea. In particular, the use of valproate for initial monotherapy has not decreased over the past nine years. This result calls not only for reinforcement of education regarding anticonvulsant selection but also for monitoring the actual prescription.
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Affiliation(s)
- Su-Hyun Han
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Hyesung Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea; Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Hye-Jin Moon
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea.
| | - Seo-Young Lee
- Department of Neurology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
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Riberto M, Matias I, Caldas CCT, Menezes-Reis R, Liporaci R, Santos M, Silva Lopes L, Machado H. Early intensive inpatient rehabilitation for children undergoing hemispherotomy. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2021. [DOI: 10.4103/jisprm.jisprm_26_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Uribe-Cardenas R, Boyke AE, Schwarz JT, Morgenstern PF, Greenfield JP, Schwartz TH, Rutka JT, Drake J, Hoffman CE. Utility of invasive electroencephalography in children 3 years old and younger with refractory epilepsy. J Neurosurg Pediatr 2020; 26:648-653. [PMID: 32947255 DOI: 10.3171/2020.6.peds19504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 06/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early surgical intervention for pediatric refractory epilepsy is increasingly advocated as surgery has become safer and data have demonstrated improved outcomes with early seizure control. There is concern that the risks associated with staged invasive electroencephalography (EEG) in very young children outweigh the potential benefits. Here, the authors present a cohort of children with refractory epilepsy who were referred for invasive monitoring, and they evaluate the role and safety of staged invasive EEG in those 3 years old and younger. METHODS The authors conducted a retrospective review of children 3 years and younger with epilepsy, who had been managed surgically at two institutions between 2001 and 2015. A cohort of pediatric patients older than 3 years of age was used for comparison. Demographics, seizure etiology, surgical management, surgical complications, and adverse events were recorded. Statistical analysis was completed using Stata version 13. A p < 0.05 was considered statistically significant. Fisher's exact test was used to compare proportions. RESULTS Ninety-four patients (45 patients aged ≤ 3 [47.9%]) and 208 procedures were included for analysis. Eighty-six procedures (41.3%) were performed in children younger than 3 years versus 122 in the older cohort (58.7%). Forty-two patients underwent grid placement (14 patients aged ≤ 3 [33.3%]); 3 of them developed complications associated with the implant (3/42 [7.14%]), none of whom were among the younger cohort. Across all procedures, 11 complications occurred in the younger cohort versus 5 in the older patients (11/86 [12.8%] vs 5/122 [4.1%], p = 0.032). Two adverse events occurred in the younger group versus 1 in the older group (2/86 [2.32%] vs 1/122 [0.82%], p = 0.571). Following grid placement, 13/14 younger patients underwent guided resections compared to 20/28 older patients (92.9% vs 71.4%, p = 0.23). CONCLUSIONS While overall complication rates were higher in the younger cohort, subdural grid placement was not associated with an increased risk of surgical complications in that population. Invasive electrocorticography informs management in very young children with refractory, localization-related epilepsy and should therefore be used when clinically indicated.
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Affiliation(s)
- Rafael Uribe-Cardenas
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | | | - Justin T Schwarz
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - Peter F Morgenstern
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - Jeffrey P Greenfield
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - Theodore H Schwartz
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - James T Rutka
- 3Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Drake
- 3Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Caitlin E Hoffman
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
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Phuong TH, Houot M, Méré M, Denos M, Samson S, Dupont S. Cognitive impairment in temporal lobe epilepsy: contributions of lesion, localization and lateralization. J Neurol 2020; 268:1443-1452. [PMID: 33216221 DOI: 10.1007/s00415-020-10307-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/05/2020] [Accepted: 11/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cognitive impairment is an important comorbidity of refractory temporal lobe epilepsy (TLE). We aimed to explore the impact of (i) specific lesions, such as dysembryoplastic neuroepithelial tumor (DNET), dysplasia, or hippocampal sclerosis, (ii) focus localization (medial versus lateral) and (iii) focus lateralization (right versus left) on the neuropsychological profile of refractory TLE adult patients. METHODS We examined the neuropsychological characteristics of 312 adults with refractory TLE: 100 patients without hippocampal sclerosis (HS) and 212 with HS. Scores on tests of intelligence (Global IQ, Verbal IQ and Performance IQ), working memory, episodic memory (verbal and visual learning and forgetting), executive functions and language abilities were analyzed. RESULTS Three main factors influenced the neuropsychological profile of refractory TLE patients: (i) the lesion, patients with HS obtaining poorer cognitive performances than patients without HS and specifically DNET patients performing better than patients with HS, (ii) the focus side, that seems only relevant for verbal memory abilities which are affected in left but not right TLE patients and (iii) the localization of seizure focus, patients with medial TLE exhibiting lower memory performances than patients with lateral TLE. CONCLUSION Lesion, localization and lateralization are major contributors of the cognitive impairment depicted in TLE. Hippocampal sclerosis appears as the main contributor.
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Affiliation(s)
- Thanh Ha Phuong
- Rehabilitation Unit, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.,Neurology Unit, Hôpital Bach Mai, Hanoi, Vietnam
| | - Marion Houot
- Clinical Investigation Centre, Institut du Cerveau Et de La Moelle Épinière (ICM), Pitié-Salpêtrière Hospital Paris, Paris, France.,Department of Neurology, Institute of Memory and Alzheimer's Disease (IM2A), AP-HP, Pitié-Salpêtrière Hospital, Paris, France.,Centre of Excellence of Neurodegenerative Disease (CoEN), AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Marie Méré
- Epilepsy Unit, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Marisa Denos
- Rehabilitation Unit, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Séverine Samson
- Univ. Lille, ULR 4072-PSITEC-Psychologie: Interactions Temps Émotions Cognition, F-59000, Lille, France
| | - Sophie Dupont
- Rehabilitation Unit, AP-HP, Pitié-Salpêtrière Hospital, Paris, France. .,Epilepsy Unit, AP-HP, Pitié-Salpêtrière Hospital, Paris, France. .,Université Paris Sorbonne, Paris, France. .,Centre de Recherche de l'Institut du Cerveau Et de La Moelle Épinière (ICM), UMPC-UMR 7225 CNRS-UMRS 975 Inserm, Paris, France.
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8
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Kim H, Faught E, Thurman DJ, Fishman J, Kalilani L. Antiepileptic Drug Treatment Patterns in Women of Childbearing Age With Epilepsy. JAMA Neurol 2020; 76:783-790. [PMID: 30933252 DOI: 10.1001/jamaneurol.2019.0447] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Limited population-based data are available on antiepileptic drug (AED) treatment patterns in women of childbearing age with epilepsy; the current population risk is not clear. Objectives To examine the AED treatment patterns and identify differences in use of valproate sodium and topiramate by comorbidities among women of childbearing age with epilepsy. Design, Setting, and Participants A retrospective cohort study used a nationwide commercial database and supplemental Medicare as well as Medicaid insurance claims data to identify 46 767 women with epilepsy aged 15 to 44 years. The eligible study cohort was enrolled between January 1, 2009, and December 31, 2013. Data analysis was conducted from January 1, 2017, to February 22, 2018. Exposures Cases required an International Classification of Diseases, Ninth Revision, Clinical Modification-coded epilepsy diagnosis with continuous medical and pharmacy enrollment. Incident cases required a baseline of 2 or more years without an epilepsy diagnosis or AED prescription before the index date. For both incident and prevalent cases, focal and generalized epilepsy cohorts were matched by age, payer type, and enrollment period and then compared. Main Outcomes and Measures Antiepileptic drug treatment pattern according to seizure type and comorbidities. Results Of the 46 767 patients identified, there were 8003 incident cases (mean [SD] age, 27.3 [9.4] years) and 38 764 prevalent cases (mean [SD] age, 29.7 [9.0] years). Among 3219 women in the incident epilepsy group who received AEDs for 90 days or more, 3173 (98.6%) received monotherapy as first-line treatment; among 28 239 treated prevalent cases, 18 987 (67.2%) received monotherapy. In 3544 (44.3%) incident cases and 9480 (24.5%) prevalent cases, AED treatment was not documented during 180 days or more of follow-up after diagnosis. Valproate (incident: 35 [5.81%]; prevalent: 514 [13.1%]) and phenytoin (incident: 33 [5.48%]; prevalent: 178 [4.53%]) were more commonly used for generalized epilepsy and oxcarbazepine (incident: 53 [8.03%]; prevalent: 386 [9.89%]) was more often used for focal epilepsy. Levetiracetam (incident: focal, 267 [40.5%]; generalized, 271 [45.0%]; prevalent: focal, 794 [20.3%]; generalized, 871 [22.2%]), lamotrigine (incident: focal, 123 [18.6%]; generalized, 106 [17.6%]; prevalent: focal, 968 [24.8%]; generalized, 871 [22.2%]), and topiramate (incident: focal, 102 [15.5%]; generalized, 64 [10.6%]; prevalent: focal, 499 [12.8%]; generalized, 470 [12.0%]) were leading AEDs prescribed for both focal and generalized epilepsy. Valproate was more commonly prescribed for women with comorbid headache or migraine (incident: 53 of 1251 [4.2%]; prevalent: 839 of 8046 [10.4%]), mood disorder (incident: 63 of 860 [7.3%]; prevalent: 1110 of 6995 [15.9%]), and anxiety and dissociative disorders (incident: 57 of 881 [6.5%]; prevalent: 798 of 5912 [13.5%]). Topiramate was more likely prescribed for those with comorbid headache or migraine (incident: 335 of 1251 [26.8%]; prevalent: 2322 of 8046 [28.9%]). Conclusions and Relevance Many women appear to be treated with valproate and topiramate despite known teratogenicity risks. Comorbidities may affect selecting certain AEDs despite their teratogenicity risks.
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Affiliation(s)
- Hyunmi Kim
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California
| | - Edward Faught
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - David J Thurman
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
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Ibhazehiebo K, Gavrilovici C, de la Hoz CL, Ma SC, Rehak R, Kaushik G, Meza Santoscoy PL, Scott L, Nath N, Kim DY, Rho JM, Kurrasch DM. A novel metabolism-based phenotypic drug discovery platform in zebrafish uncovers HDACs 1 and 3 as a potential combined anti-seizure drug target. Brain 2018; 141:744-761. [PMID: 29373639 PMCID: PMC5837409 DOI: 10.1093/brain/awx364] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 10/29/2017] [Accepted: 11/05/2017] [Indexed: 01/01/2023] Open
Abstract
Despite the development of newer anti-seizure medications over the past 50 years, 30-40% of patients with epilepsy remain refractory to treatment. One explanation for this lack of progress is that the current screening process is largely biased towards transmembrane channels and receptors, and ignores intracellular proteins and enzymes that might serve as efficacious molecular targets. Here, we report the development of a novel drug screening platform that harnesses the power of zebrafish genetics and combines it with in vivo bioenergetics screening assays to uncover therapeutic agents that improve mitochondrial health in diseased animals. By screening commercially available chemical libraries of approved drugs, for which the molecular targets and pathways are well characterized, we were able to reverse-identify the proteins targeted by efficacious compounds and confirm the physiological roles that they play by utilizing other pharmacological ligands. Indeed, using an 870-compound screen in kcna1-morpholino epileptic zebrafish larvae, we uncovered vorinostat (Zolinza™; suberanilohydroxamic acid, SAHA) as a potent anti-seizure agent. We further demonstrated that vorinostat decreased average daily seizures by ∼60% in epileptic Kcna1-null mice using video-EEG recordings. Given that vorinostat is a broad histone deacetylase (HDAC) inhibitor, we then delineated a specific subset of HDACs, namely HDACs 1 and 3, as potential drug targets for future screening. In summary, we have developed a novel phenotypic, metabolism-based experimental therapeutics platform that can be used to identify new molecular targets for future drug discovery in epilepsy.
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Affiliation(s)
- Kingsley Ibhazehiebo
- Department of Medical Genetics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Canada
| | - Cezar Gavrilovici
- Alberta Children’s Hospital Research Institute, University of Calgary, Canada
- Departments of Pediatrics, Clinical Neurosciences, Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Cristiane L de la Hoz
- Department of Medical Genetics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Canada
| | - Shun-Chieh Ma
- Departments of Neurology and Neurobiology, Barrow Neurological Institute, St Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Renata Rehak
- Department of Medical Genetics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Canada
| | - Gaurav Kaushik
- Department of Medical Genetics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Canada
| | - Paola L Meza Santoscoy
- Department of Medical Genetics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Canada
| | - Lucas Scott
- Alberta Children’s Hospital Research Institute, University of Calgary, Canada
- Departments of Pediatrics, Clinical Neurosciences, Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nandan Nath
- Department of Medical Genetics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Canada
| | - Do-Young Kim
- Departments of Neurology and Neurobiology, Barrow Neurological Institute, St Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jong M Rho
- Alberta Children’s Hospital Research Institute, University of Calgary, Canada
- Departments of Pediatrics, Clinical Neurosciences, Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Deborah M Kurrasch
- Department of Medical Genetics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Canada
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Packer RMA, McGreevy PD, Salvin HE, Valenzuela MJ, Chaplin CM, Volk HA. Cognitive dysfunction in naturally occurring canine idiopathic epilepsy. PLoS One 2018; 13:e0192182. [PMID: 29420639 PMCID: PMC5805257 DOI: 10.1371/journal.pone.0192182] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/17/2018] [Indexed: 12/27/2022] Open
Abstract
Globally, epilepsy is a common serious brain disorder. In addition to seizure activity, epilepsy is associated with cognitive impairments including static cognitive impairments present at onset, progressive seizure-induced impairments and co-morbid dementia. Epilepsy occurs naturally in domestic dogs but its impact on canine cognition has yet to be studied, despite canine cognitive dysfunction (CCD) recognised as a spontaneous model of dementia. Here we use data from a psychometrically validated tool, the canine cognitive dysfunction rating (CCDR) scale, to compare cognitive dysfunction in dogs diagnosed with idiopathic epilepsy (IE) with controls while accounting for age. An online cross-sectional study resulted in a sample of 4051 dogs, of which n = 286 had been diagnosed with IE. Four factors were significantly associated with a diagnosis of CCD (above the diagnostic cut-off of CCDR ≥50): (i) epilepsy diagnosis: dogs with epilepsy were at higher risk; (ii) age: older dogs were at higher risk; (iii) weight: lighter dogs (kg) were at higher risk; (iv) training history: dogs with more exposure to training activities were at lower risk. Impairments in memory were most common in dogs with IE, but progression of impairments was not observed compared to controls. A significant interaction between epilepsy and age was identified, with IE dogs exhibiting a higher risk of CCD at a young age, while control dogs followed the expected pattern of low-risk throughout middle age, with risk increasing exponentially in geriatric years. Within the IE sub-population, dogs with a history of cluster seizures and high seizure frequency had higher CCDR scores. The age of onset, nature and progression of cognitive impairment in the current IE dogs appear divergent from those classically seen in CCD. Longitudinal monitoring of cognitive function from seizure onset is required to further characterise these impairments.
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Affiliation(s)
- Rowena M. A. Packer
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, Hertfordshire, United Kingdom
| | - Paul D. McGreevy
- Sydney School of Veterinary Science, Faculty of Science, The University of Sydney, New South Wales, Australia
| | - Hannah E. Salvin
- Sydney School of Veterinary Science, Faculty of Science, The University of Sydney, New South Wales, Australia
| | - Michael J. Valenzuela
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Chloe M. Chaplin
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, Hertfordshire, United Kingdom
| | - Holger A. Volk
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, Hertfordshire, United Kingdom
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Kim HJ, Lee JH, Park CH, Hong HS, Choi YS, Yoo JH, Lee HW. Role of Language-Related Functional Connectivity in Patients with Benign Childhood Epilepsy with Centrotemporal Spikes. J Clin Neurol 2018; 14:48-57. [PMID: 29629540 PMCID: PMC5765256 DOI: 10.3988/jcn.2018.14.1.48] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 12/20/2022] Open
Abstract
Background and Purpose Benign childhood epilepsy with centrotemporal spikes (BECTS) does not always have a benign cognitive outcome. We investigated the relationship between cognitive performance and altered functional connectivity (FC) in the resting-state brain networks of BECTS patients. Methods We studied 42 subjects, comprising 19 BECTS patients and 23 healthy controls. Cognitive performance was assessed using the Korean version of the Wechsler Intelligence Scale for Children-III, in addition to verbal and visuospatial memory tests and executive function tests. Resting-state functional magnetic resonance imaging was acquired in addition to high-resolution structural data. We selected Rolandic and language-related areas as regions of interest (ROIs) and analyzed the seed-based FC to voxels throughout the brain. We evaluated the correlations between the neuropsychological test scores and seed-based FC values using the same ROIs. Results The verbal intelligence quotient (VIQ) and full-scale intelligence quotient (FSIQ) were lower in BECTS patients than in healthy controls (p<0.001). The prevalence of subjects with a higher performance IQ than VIQ was significantly higher in BECTS patients than in healthy controls (73.7% vs. 26.1%, respectively; p=0.002). Both the Rolandic and language-related ROIs exhibited more enhanced FC to voxels in the left inferior temporal gyrus in BECTS patients than in healthy controls. A particularly interestingly finding was that the enhanced FC was correlated with lower cognitive performance as measured by the VIQ and the FSIQ in both patients and control subjects. Conclusions Our findings suggest that the FC alterations in resting-state brain networks related to the seizure onset zone and language processing areas could be related to adaptive plasticity for coping with cognitive dysfunction.
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Affiliation(s)
- Hyeon Jin Kim
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea.,Department of Medical Science, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Jung Hwa Lee
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea.,Department of Neurology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine and Samsung Biomedical Research Institute, Changwon, Korea
| | - Chang Hyun Park
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea.,Department of Medical Science, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Hye Sun Hong
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea.,Department of Medical Science, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Yun Seo Choi
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea.,Department of Medical Science, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Jeong Hyun Yoo
- Department of Radiology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Hyang Woon Lee
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea.,Department of Medical Science, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea.
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Neto FK, Noschang R, Nunes ML. The relationship between epilepsy, sleep disorders, and attention deficit hyperactivity disorder (ADHD) in children: A review of the literature. ACTA ACUST UNITED AC 2016; 9:158-163. [PMID: 28123654 PMCID: PMC5241617 DOI: 10.1016/j.slsci.2016.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 09/04/2016] [Accepted: 09/22/2016] [Indexed: 11/28/2022]
Abstract
Objective To analyze the relationship between epilepsy, sleep disorders, and attention deficit hyperactivity disorder (ADHD). Bibliographic search A literature search of the PubMed database was performed using the following key words: epilepsy, sleep, and ADHD. In total, 91 articles were located in PubMed, 34 were selected for abstract reading and twelve articles were reviewed, in which the main objectives were examine the relationship between epilepsy, sleep and ADHD from several perspectives, including epidemiology, effect of comorbidities on academic performance and the factors leading to diagnostic difficulties among these three disorders Results Among the main findings, there were difficulties to start and maintain sleep in patients with epilepsy and ADHD, reduction in sleep efficiency, decreased seizure threshold, as well as behavioral and cognitive deficits in both groups. Conclusions It is important to know which symptom is the predominant one. For this reason, children and adolescents with epilepsy, ADHD and sleep disorders need to be assessed carefully before initiating treatment. Our review concluded that there is an important link in this pathological triad.
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Affiliation(s)
- Felipe Kalil Neto
- Division of Neurology, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Renan Noschang
- Pontifícia Universidade Católica do Rio Grande do Sul, School of Medicine, Brazil
| | - Magda Lahorgue Nunes
- Division of Neurology, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil; Pontifícia Universidade Católica do Rio Grande do Sul, School of Medicine, Brazil; Brain Institute (InsCer) PUCRS, Brazil
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13
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Jenny B, Smoll N, El Hassani Y, Momjian S, Pollo C, Korff CM, Seeck M, Schaller K. Pediatric epilepsy surgery: could age be a predictor of outcomes? J Neurosurg Pediatr 2016; 18:235-41. [PMID: 27128787 DOI: 10.3171/2015.10.peds14413] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Like adults, many children suffering from intractable seizures benefit from surgical therapy. Although various reports indicate that early intervention may avoid severe developmental consequences often associated with intractable epilepsy, surgery is still considered a last option for many children. In this retrospective study, the authors aimed to determine whether pediatric epilepsy surgery, in particular during the first years of life, relates to measurable benefits. METHODS Data from 78 patients (age range 5 months to 17 years) who underwent epilepsy surgery at the Geneva and Lausanne University Hospitals between 1997 and 2012 were reviewed retrospectively. Patients were dichotomized into 2 groups: infants (≤ 3 years of age, n = 19), and children/adolescents (4-17 years of age, n = 59). Compared with children/adolescents, infants more often had a diagnosis of dysplasia (37% vs 10%, respectively; p < 0.05, chi-square test). RESULTS The overall seizure-free rate was 76.9%, with 89.5% in infants and 72.9% in the children/adolescents group. Infants were 2.76 times as likely to achieve seizure-free status as children/adolescents. Postoperative antiepileptic medication was reduced in 67.9% of patients. Only 11.4% of the patients were taking more than 2 antiepileptic drugs after surgery, compared with 43% before surgery (p < 0.0001). The overall complication rate was 15.1% (6.4% transient hemiparesis), and no major complications or deaths occurred. CONCLUSIONS The data show a high seizure-free rate in children ≤ 3 years of age, despite a higher occurrence of dysplastic, potentially ill-defined lesions. Pediatric patients undergoing epilepsy surgery can expect a significant reduction in their need for medication. Given the excellent results in the infant group, prospective studies are warranted to determine whether age ≤ 3 years is a predictor for excellent surgical outcome.
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Affiliation(s)
| | | | | | | | - Claudio Pollo
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Christian M Korff
- Child and Adolescents, Pediatric Neurology, University Hospital Geneva, Switzerland; and
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14
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Kim EH, Ko TS. Cognitive impairment in childhood onset epilepsy: up-to-date information about its causes. KOREAN JOURNAL OF PEDIATRICS 2016; 59:155-64. [PMID: 27186225 PMCID: PMC4865638 DOI: 10.3345/kjp.2016.59.4.155] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 11/02/2015] [Accepted: 11/16/2015] [Indexed: 11/27/2022]
Abstract
Cognitive impairment associated with childhood-onset epilepsy is an important consequence in the developing brain owing to its negative effects on neurodevelopmental and social outcomes. While the cause of cognitive impairment in epilepsy appears to be multifactorial, epilepsy-related factors such as type of epilepsy and underlying etiology, age at onset, frequency of seizures, duration of epilepsy, and its treatment are considered important. In recent studies, antecedent cognitive impairment before the first recognized seizure and microstructural and functional alteration of the brain at onset of epilepsy suggest the presence of a common neurobiological mechanism between epilepsy and cognitive comorbidity. However, the overall impact of cognitive comorbidity in children with epilepsy and the independent contribution of each of these factors to cognitive impairment have not been clearly delineated. This review article focuses on the significant contributors to cognitive impairment in children with epilepsy.
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Affiliation(s)
- Eun-Hee Kim
- Department of Pediatrics, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Tae-Sung Ko
- Division of Pediatric Neurology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, Korea
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Murru A, Popovic D, Pacchiarotti I, Hidalgo D, León-Caballero J, Vieta E. Management of adverse effects of mood stabilizers. Curr Psychiatry Rep 2015; 17:603. [PMID: 26084665 DOI: 10.1007/s11920-015-0603-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Mood stabilizers such as lithium and anticonvulsants are still standard-of-care for the acute and long-term treatment of bipolar disorder (BD). This systematic review aimed to assess the prevalence of their adverse effects (AEs) and to provide recommendations on their clinical management. We performed a systematic research for studies reporting the prevalence of AEs with lithium, valproate, lamotrigine, and carbamazepine/oxcarbazepine. Management recommendations were then developed. Mood stabilizers have different tolerability profiles and are eventually associated to cognitive, dermatological, endocrine, gastrointestinal, immunological, metabolic, nephrogenic, neurologic, sexual, and teratogenic AEs. Most of those can be transient or dose-related and can be managed by optimizing drug doses to the lowest effective dose. Some rare AEs can be serious and potentially lethal, and require abrupt discontinuation of medication. Integrated medical attention is warranted for complex somatic AEs. Functional remediation and psychoeducation may help to promote awareness on BD and better medication management.
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Affiliation(s)
- Andrea Murru
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain,
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Helmstaedter C, Witt JA. Comments on Ortinski P et al. Cognitive side effects of antiepileptic drugs. Epilepsy & behavior 2004;5(Suppl. 1):S60-65. Epilepsy Behav 2014; 40:29-31. [PMID: 25453546 DOI: 10.1016/j.yebeh.2014.09.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 09/23/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
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Busch RM. Comments on Motamedi G, Meador K. Epilepsy and cognition. Epilepsy & behavior 2003;4:S25-S28. Epilepsy Behav 2014; 40:26-8. [PMID: 25307191 PMCID: PMC4391193 DOI: 10.1016/j.yebeh.2014.08.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 08/10/2014] [Indexed: 01/08/2023]
Affiliation(s)
- Robyn M Busch
- Cleveland Clinic Epilepsy Center, 9500 Euclid Avenue, P57, Cleveland, OH 44195, USA.
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Anticonvulsant Effect of Antiaris toxicaria (Pers.) Lesch. (Moraceae) Aqueous Extract in Rodents. ISRN PHARMACOLOGY 2013; 2013:519208. [PMID: 24167736 PMCID: PMC3791639 DOI: 10.1155/2013/519208] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 08/13/2013] [Indexed: 11/17/2022]
Abstract
Antiaris toxicaria (Moraceae) was evaluated for anticonvulsant activity in rodents. Animal models used include maximal electroshock test (MEST); pentylenetetrazole-induced (PTZ) convulsions; picrotoxin-induced (PCT) convulsions; strychnine- (STR-) and 4-aminopyridine-induced convulsions. Increase in latency to seizures as well as reduction in duration and frequency of seizures indicated anticonvulsant activity. The extract was more effective in all models used except the maximal electroshock test and strychnine-induced convulsions. Antiaris toxicaria aqueous extract (200, 400, and 800 mg kg(-1)) significantly (P < 0.05 - 0.01) shortened the duration of convulsions in PTZ- and PCT-induced seizures. Delay in the onset of convulsions in the two tests was significant (P < 0.001). Reduction in the frequency of seizures was also significant (P < 0.05 - 0.001) in both tests. Antiaris further delayed the onset of seizures in 4-aminopyridine model while producing 75% protection against death in mice. Diazepam (0.1, 0.3, and 1 mg kg(-1)), carbamazepine (3, 10, and 30 mg kg(-1)), and sodium valproate (100-400 mg kg(-1)) were used as reference anticonvulsant drugs for various models. Flumazenil blocked the effect of the extract in the PTZ test significantly suggesting that Antiaris toxicaria may be acting by enhancing the effects of the GABAergic system. Antiaris toxicaria aqueous extract therefore possesses anticonvulsant activity.
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Primum non nocere: are seizure medications safe in neonates? Epilepsy Curr 2013; 13:179-81. [PMID: 24009483 DOI: 10.5698/1535-7597-13.4.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
Antiepileptic drugs (AEDs) are used by millions of people worldwide for the treatment of epilepsy, as well as in many other neurological and psychiatric conditions. They are frequently associated with adverse effects (AEs), which have an impact on the tolerability and success of treatment. Half the people who develop intolerable AEs discontinue treatment early on after initiation, while the majority of people will continue to be exposed to their effects for long periods of time. The long-term safety of AEDs reflects their potential for chronic, cumulative dose effects; rare, but potentially serious late idiosyncratic effects; late, dose-related effects; and delayed, teratogenic or neurodevelopmental effects. These AEs can affect every body system and are usually insidious. With the exception of delayed effects, most other late or chronic AEs are reversible. To date, there is no clear evidence of a carcinogenic effect of AEDs in humans. While physicians are aware of the long-term AEs of old AEDs (the traditional liver enzyme-inducing AEDs and valproate), information about AEs of new AEDs (such as lamotrigine, levetiracetam, oxcarbazepine, topiramate or zonisamide), particularly of their teratogenic effects, has emerged over the years. Sporadic publications have raised issues about AEs of the newer AEDs eslicarbazepine, retigabine, rufinamide, lacosamide and perampanel but their long-term safety profiles may take years to be fully appreciated. Physicians should not only be aware of the late and chronic AEs of AEDs but should systematically enquire and screen for these according to the individual AED AE profile. Care should be taken for individuals with comorbid conditions that may render them more susceptible to specific AEs. Prevention and appropriate management of long-term AED AEs is expected to improve adherence to treatment, quality of life and control of epilepsy.
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Abstract
Newer treatments have resulted in increasing numbers of survivors of childhood cancer, for whom neurological and neurocognitive toxicity directly impacts overall functioning and quality of life. There are multiple disease- and host-related factors that influence the development of cancer-related neurocognitive dysfunction, which can progress over time and lead to significant functional impairments. This article provides an overview of the types of neurocognitive deficits seen in survivors of childhood brain tumors, the tools used to assess neurocognitive function, and the factors that impact its severity. This provides a framework for consideration of potential areas for primary prevention by reducing treatment-related toxicity as well as interventions, using behavioral and pharmacologic treatments.
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Affiliation(s)
- Nicole J Ullrich
- Department of Neurology, Children's Hospital Boston, Boston, MA, USA.
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