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Hernández García E, Naranjo L, Pichardo-Macías LA, Bernad Bernad MJ, Castro-Pastrana LI, Ruíz García M, García Bernal TA, Mendoza Solís JL, Calderón Guzmán D, Díaz-García L, Mendoza-Torreblanca JG, Chávez Pacheco JL. Analysis of Adverse Drug Reactions in Pediatric Patients with Epilepsy: An Intensive Pharmacovigilance Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1775. [PMID: 38002866 PMCID: PMC10670375 DOI: 10.3390/children10111775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023]
Abstract
Epilepsy is a chronic neurological disease characterized by the presence of spontaneous seizures, with a higher incidence in the pediatric population. Anti-seizure medication (ASM) may produce adverse drug reactions (ADRs) with an elevated frequency and a high severity. Thus, the objective of the present study was to analyze, through intensive pharmacovigilance over 112 months, the ADRs produced by valproic acid (VPA), oxcarbazepine (OXC), phenytoin (PHT), and levetiracetam (LEV), among others, administered to monotherapy or polytherapy for Mexican hospitalized pediatric epilepsy patients. A total of 1034 patients were interviewed; 315 met the inclusion criteria, 211 patients presented ADRs, and 104 did not. A total of 548 ASM-ADRs were identified, and VPA, LEV, and PHT were the main culprit drugs. The most frequent ADRs were drowsiness, irritability, and thrombocytopenia, and the main systems affected were hematologic, nervous, and dermatologic. LEV and OXC caused more nonsevere ADRs, and PHT caused more severe ADRs. The risk analysis showed an association between belonging to the younger groups and polytherapy with ADR presence and between polytherapy and malnutrition with severe ADRs. In addition, most of the severe ADRs were preventable, and most of the nonsevere ADRs were nonpreventable.
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Affiliation(s)
- Ernestina Hernández García
- Laboratorio de Farmacología, Subdirección de Medicina Experimental, Instituto Nacional de Pediatría, Ciudad de Mexico 04530, Mexico;
- Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud, Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), Ciudad de Mexico 04960, Mexico
| | - Lizbeth Naranjo
- Departamento de Matemáticas, Facultad de Ciencias, Universidad Nacional Autónoma de Mexico, Ciudad de Mexico 04510, Mexico;
| | - Luz Adriana Pichardo-Macías
- Departamento de Fisiología, Instituto Politécnico Nacional, Escuela Nacional de Ciencias Biológicas, Ciudad de Mexico 07738, Mexico;
| | - María Josefa Bernad Bernad
- Departamento de Farmacia, Facultad de Química, Universidad Nacional Autónoma de Mexico, Ciudad de Mexico 04510, Mexico;
| | | | - Matilde Ruíz García
- Servicio de Neurología, Dirección Médica, Instituto Nacional de Pediatría, Ciudad de Mexico 04530, Mexico;
| | | | | | - David Calderón Guzmán
- Laboratorio de Neurociencias, Subdirección de Medicina Experimental, Instituto Nacional de Pediatría, Ciudad de Mexico 04530, Mexico; (D.C.G.); (J.G.M.-T.)
| | - Luisa Díaz-García
- Departamento de Metodología de la Investigación, Subdirección de Investigación Clínica, Instituto Nacional de Pediatría, Ciudad de Mexico 04530, Mexico;
| | - Julieta Griselda Mendoza-Torreblanca
- Laboratorio de Neurociencias, Subdirección de Medicina Experimental, Instituto Nacional de Pediatría, Ciudad de Mexico 04530, Mexico; (D.C.G.); (J.G.M.-T.)
| | - Juan Luis Chávez Pacheco
- Laboratorio de Farmacología, Subdirección de Medicina Experimental, Instituto Nacional de Pediatría, Ciudad de Mexico 04530, Mexico;
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Shen L, Wang M, Zhao J, Ruan Y, Yang J, Chai S, Dai X, Yang B, Cai Y, Zhou Y, Mei Z, Zheng Z, Xu D, Guo H, Lei Y, Cheng R, Yue C, Wang T, Zhao Y, Liu X, Chai Y, Chen J, Du H, Xiong N. Study on the relationship between obesity and complications of Pediatric Epilepsy surgery. BMC Pediatr 2023; 23:142. [PMID: 36997989 PMCID: PMC10061988 DOI: 10.1186/s12887-023-03948-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 03/09/2023] [Indexed: 04/01/2023] Open
Abstract
OBJECTIVE Studies have shown that obesity has a significant impact on poor surgical outcomes. However, the relationship between obesity and pediatric epilepsy surgery has not been reported. This study aimed to explore the relationship between obesity and complications of pediatric epilepsy surgery and the effect of obesity on the outcome of pediatric epilepsy surgery, and to provide a reference for weight management of children with epilepsy. METHODS A single-center retrospective analysis of complications in children undergoing epilepsy surgery was conducted. Body mass index (BMI) percentiles were adjusted by age and used as a criterion for assessing obesity in children. According to the adjusted BMI value, the children were divided into the obese group (n = 16) and nonobese group (n = 20). The intraoperative blood loss, operation time, and postoperative fever were compared between the two groups. RESULTS A total of 36 children were included in the study, including 20 girls and 16 boys. The mean age of the children was 8.0 years old, ranging from 0.8 to 16.9 years old. The mean BMI was 18.1 kg/m2, ranging from 12.4 kg/m2 to 28.3 kg/m2. Sixteen of them were overweight or obese (44.4%). Obesity was associated with higher intraoperative blood loss in children with epilepsy (p = 0.04), and there was no correlation between obesity and operation time (p = 0.21). Obese children had a greater risk of postoperative fever (56.3%) than nonobese children (55.0%), but this was statistically nonsignificant (p = 0.61). The long-term follow-up outcomes showed that 23 patients (63.9%) were seizure-free (Engel grade I), 6 patients (16.7%) had Engel grade II, and 7 patients (19.4%) had Engel grade III. There was no difference in long-term seizure control outcomes between obese and nonobese groups (p = 0.682). There were no permanent neurological complications after surgery. CONCLUSION Compared with nonobese children with epilepsy, obese children with epilepsy had a higher intraoperative blood loss. It is necessary to conduct early weight management of children with epilepsy as long as possible.
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Affiliation(s)
- Lei Shen
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Mengyang Wang
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Jingwei Zhao
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Yuanyuan Ruan
- Department of Neurosurgery, Wuhan Children's Hospital, 430010, Wuhan, Hubei, China
| | - Jingyi Yang
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Songshan Chai
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Xuan Dai
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Bangkun Yang
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Yuankun Cai
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Yixuan Zhou
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Zhimin Mei
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Zhixin Zheng
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Dongyuan Xu
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Hantao Guo
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Yu Lei
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Runqi Cheng
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Chuqiao Yue
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Tiansheng Wang
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Yunchang Zhao
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Xinyu Liu
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Yibo Chai
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Jingcao Chen
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China
| | - Hao Du
- Department of Neurosurgery, Wuhan Children's Hospital, 430010, Wuhan, Hubei, China.
| | - Nanxiang Xiong
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 430071, Wuhan, Hubei, China.
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Identification of factors associated with new-onset vascular disease in patients admitted for video-EEG monitoring: A longitudinal cohort study. Epilepsy Behav 2022; 135:108883. [PMID: 36027868 DOI: 10.1016/j.yebeh.2022.108883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/19/2022] [Accepted: 08/10/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE People with epilepsy are at a higher risk of developing vascular disease. Understanding the risk factors in observational studies is hampered by the challenge in separating epilepsy-related risk and treatment-related risk, and uncertainty in the epilepsy diagnosis. This study aimed to identify factors associated with risk of subsequent vascular disease in patients with video-EEG monitoring (VEM) confirmed epilepsy. METHODS We included patients with a diagnosis of epilepsy and nonepileptic disorders between January 1, 1995, and December 31, 2015. Incident cardiovascular, cerebrovascular, and peripheral vascular disease was determined by linkage to a state-wide hospital admissions database between 1st July 1994 and 28th February 2018. Incidence was compared with the general population. RESULTS 1728 patients (59.7% female, median age 35 years) underwent VEM, and were followed up for a median of 9.2 years (range 2.2-22.9 years). Eight-hundred and thirty -two were diagnosed with epilepsy and 896 nonepileptic disorders. The incidence of cerebrovascular disease was higher in both patients with epilepsy (incidence rate ratio [IRR] 1.78, p = 0.001) and with nonepileptic disorders (IRR 1.61, p < 0.001) than in the general population. Patients who took valproic acid (VPA) were at a lower risk of vascular disease than those taking enzyme-inducing antiseizure medications (EIASM, subdistribution hazard ratio [SHR] 0.42, p = 0.013), and those taking neither VPA nor EIASM (SHR 0.47, p = 0.03). There was no difference in the incidence of vascular disease between patients with epilepsy and those without epilepsy (SHR 0.94, p = 0.766). Factors associated with increased risk included age (SHR 1.04, p < 0.001), male sex (SHR 1.50, p = 0.017), and smoking (SHR 1.68, p = 0.017). SIGNIFICANCE In this study, both patients with epilepsy and without epilepsy had increased vascular risk. This suggests that the increased risk may be in part due to factors not directly related to epilepsy, such as EIASM use and vascular risk factors.
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Zhang T, Feng H, Xiao W, Li J, Liu Q, Feng X, Qi D, Fan X, Shan Y, Yu T, Zhao G, Wang T. Prophylactic administration of tranexamic acid combined with thromboelastography-guided hemostatic algorithm reduces allogeneic transfusion requirements during pediatric resective epilepsy surgery: A randomized controlled trial. Front Pharmacol 2022; 13:916017. [PMID: 36059956 PMCID: PMC9428586 DOI: 10.3389/fphar.2022.916017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Intraoperative bleeding and allogeneic transfusion remain common problems in pediatric resective epilepsy surgery. Tranexamic acid (TXA) is a widely recommended antifibrinolytic drug that reduces blood loss and transfusion requirements for bleeding patients. Thromboelastography (TEG)-guided hemostatic algorithm is commonly used in bleeding management. This trial was designed to validate the efficacy of a multimodal coagulation therapy involving continuous TXA infusion with TEG-guided hemostatic algorithm in reducing allogeneic exposure risk in pediatric resective epilepsy surgery. Methods: Eighty-three children undergoing resective epilepsy surgery were randomized into a treatment group (Group T; n = 42) and a control group (Group C; n = 41). Group T received prophylactic TXA (10 mg/kg followed by 5 mg/kg/h) with TEG-guided hemostatic algorithm, whereas Group C received conventional coagulation management. The primary outcome was allogeneic transfusion rate during surgery, and the secondary outcomes were intraoperative blood loss, incidence of postoperative seizures, and thromboembolic events during hospitalization. Results: The incidence of intraoperative allogeneic transfusion reduced by 34.7% with the use of a multimodal coagulation therapy (19.0% in Group T vs. 53.7% in Group C; RR 0.355, 95% CI 0.179–0.704; p = 0.001). This was mainly triggered by a significant reduction (44.1%) in intraoperative plasma transfusion (7.1% in Group T vs. 51.2% in Group C; RR 0.139, 95% CI 0.045–0.432; p = 0.000). The risk of intraoperative RBC transfusion was lower in Group T than in Group C, but the difference was not statistically significant (14.3% in Group T vs. 29.3% in Group C; RR 0.488, 95% CI 0.202–1.177; p = 0.098). No platelets were transfused in both groups. Further, 19 (45.2%) patients in Group T received fibrinogen concentrates guided by TEG data, whereas 1 (2.4%) patient in Group C received fibrinogen concentrates empirically. There were no significant differences in estimated blood loss and postoperative seizures between the two groups, and no thromboembolic events were observed after surgery. Conclusion: Prophylactic administration of TXA combined with TEG-guided hemostatic algorithm can be an effective multimodal coagulation strategy for reducing allogeneic transfusion requirements during pediatric resective epilepsy surgery. Clinical Trial Registration:www.chictr.org.cn/index.aspx, identifier ChiCTR1800016188.
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Affiliation(s)
- Ting Zhang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hua Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Xiao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jingsheng Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qinghai Liu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuexin Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Dezhou Qi
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Fan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Yu
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Tianlong Wang,
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Fei YF, Smith YR, Dendrinos ML, Rosen MW, Quint EH. Considerations in Adolescent Use of the Etonogestrel Subdermal Implant: A Cohort Study. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:780902. [PMID: 36304012 PMCID: PMC9580660 DOI: 10.3389/frph.2021.780902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/06/2021] [Indexed: 12/01/2022] Open
Abstract
Objectives: To describe bleeding patterns and other side effects in adolescent implant users and characterize their impact on early discontinuation of the implant. Study Design: This is a retrospective cohort study of female patients under 18 years who had an implant placed from 2013 to 2018. Data were collected on demographics, medical history, and side effects. Results: Of 212 adolescents, the average age at insertion was 16 years and 84% desired placement for contraception. Common side effects included AUB (80%), mood changes (10%), and perceived weight gain (9%). Most (76%) used the implant for at least 12 months. Average time to removal was 22.1 months (SD 13.0 months) and this did not depend on presence of side effects. Twenty-seven percent of teens were able to achieve amenorrhea. Adolescents with frequent or prolonged bleeding were more likely to have implant removal prior to 12 months than those with other bleeding patterns (p = 0.003). Early removal was also more common in girls reporting weight or mood issues than those who did not (p < 0.001 and p = 0.045, respectively). BMI increased in 64% of adolescents. Average percentage change in BMI was 3.2% (0.87 kg/m2). There was no difference in baseline use of any mood-modulating medications in patients who did and did not complain of mood side effects following implant placement (p = 0.801). Conclusion: Characterization of bleeding patterns following implant placement in adolescents have not previously been reported. Prolonged or heavy bleeding, mood issues, and perceived weight gain were associated with earlier removal of the implant. A relatively small number had early removal of the implant due to weight or mood complaints. Therefore, a history of obesity, depression, or other mood disorders should not be a deterrent to implant placement.
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Affiliation(s)
- Y. Frances Fei
- Section of Pediatric and Adolescent Gynecology, Nationwide Children's Hospital, Columbus, OH, United States
- *Correspondence: Y. Frances Fei
| | - Yolanda R. Smith
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Melina L. Dendrinos
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Monica W. Rosen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Elisabeth H. Quint
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
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Wong BJ, Agarwal R, Chen MI. Anesthesia for the Pediatric Patient With Epilepsy and Minimally Invasive Surgery for Epilepsy. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00457-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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8
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Evaluation of the effects of antiepileptic drugs on complete blood count parameters. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.827657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Leung P, DeVore EK, Kawai K, Yuen S, Kenna M, Irace AL, Roberson D, Adil E. Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy? Otolaryngol Head Neck Surg 2020; 165:187-196. [PMID: 33170769 DOI: 10.1177/0194599820970943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate risk factors for pediatric posttonsillectomy hemorrhage (PTH) and the need for transfusion using a national database. STUDY DESIGN Retrospective cohort study. SETTING The study was conducted using the Pediatric Health Information System (PHIS) database. METHODS Children ≤18 years who underwent tonsillectomy with or without adenoidectomy (T±A) between 2004 and 2015 were included. We evaluated the risk of PTH requiring cauterization according to patient demographics, comorbidities, indication for surgery, medications, year of surgery, and geographic region. RESULTS Of the 551,137 PHIS patients who underwent T±A, 8735 patients (1.58%) experienced a PTH. The risk of PTH increased from 1.33% (95% confidence interval [CI]: 1.15%, 1.53%) in 2010 to 1.91% (95% CI: 1.64%, 2.24%) in 2015 (P < .001). Older age (≥12 vs <5 years old: adjusted odds ratio [aOR] 3.17; 95% CI: 2.86, 3.52), male sex (aOR 1.11; 95% CI: 1.05, 1.17), medical comorbidities (aOR 1.18; 95% CI: 1.08, 1.29), recurrent tonsillitis (aOR 1.15; 95% CI: 1.07, 1.24), and intensive care unit admission (aOR 1.74; 95% CI: 1.55, 1.95) were significantly associated with an increased risk of PTH. Use of ibuprofen (aOR 1.36; 95% CI: 1.22, 1.52), ketorolac (aOR 1.39; 95% CI: 1.14, 1.69), anticonvulsant (aOR 1.23; 95% CI: 1.03, 1.76), and antidepressants (aOR 1.35; 95% CI: 1.03, 1.76) were also associated with an increased risk of PTH. The need for blood transfusion was 2.1% (181/8735). CONCLUSION The incidence of PTH increased significantly between 2011 and 2015, and ibuprofen appears to be one contributing factor. Given the benefits of ibuprofen, it is unclear whether this increased risk warrants a change in practice.
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Affiliation(s)
- Peggy Leung
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School Department of Otolaryngology, Boston, Massachusetts, USA
| | - Sonia Yuen
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Margaret Kenna
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School Department of Otolaryngology, Boston, Massachusetts, USA
| | - Alexandria L Irace
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - David Roberson
- Bayhealth Medical Center, Milford, Delaware, USA.,The Global Tracheostomy Collaborative, Raleigh, North Carolina, USA
| | - Eelam Adil
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School Department of Otolaryngology, Boston, Massachusetts, USA
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Lu MZH, Reid SM, Lundine K, Crighton G. Blood transfusion following major orthopaedic surgery in cerebral palsy: a retrospective analysis. ANZ J Surg 2020; 91:409-414. [PMID: 32893430 DOI: 10.1111/ans.16288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Progressive musculoskeletal pathology is ubiquitous among children with cerebral palsy (CP). Corrective surgery places them at risk of major blood loss and red blood cell (RBC) transfusion. Significant variability exists in uptake of perioperative patient blood management (PBM) strategies. This study aimed to examine factors contributing to RBC transfusion and assist in future development of care pathways. METHODS A retrospective review at a tertiary paediatric hospital was undertaken to identify patients with CP undergoing either primary spinal fusion or single event, multilevel surgery (SEMLS) between 2010 and 2015. Solely soft tissue procedures were excluded. Data collected included demographics, Gross Motor Function Classification System level, surgical details, perioperative PBM and transfusion rates. Univariable analysis was performed to assess contributing factors to RBC transfusion. RESULTS A total of 36 spinal fusion and 98 SEMLS patients were included. Preoperatively, 12% were anaemic, but only 19% had a ferritin checked. Overall, 49 patients (37%) received RBC transfusions. Intraoperative usage of tranexamic acid and cell salvage was 89% and 81%, respectively, for the spine cohort, and 22% and 3% for the SEMLS cohort. Successively higher Gross Motor Function Classification System levels, sodium valproate usage, longer surgical times, spinal fusion, pelvis instrumentation and more osteotomies were associated with RBC transfusion. CONCLUSION More than one-third of CP patients who underwent major orthopaedic surgery received RBC transfusion. As expected, the more severely affected patients undergoing longer procedures were at highest risk. Significant improvements can be made in PBM to help optimize patients for surgery and minimize the need for transfusion.
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Affiliation(s)
- Matthias Z H Lu
- Department of Orthopaedic Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Susan M Reid
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Kristopher Lundine
- Department of Orthopaedic Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Gemma Crighton
- Department of Haematology, Royal Children's Hospital, Melbourne, Victoria, Australia
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11
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Lee B, Bae MI, Eum D, Ntungi AM, Jun B, Min KT. Bleeding properties according to surgical sites during pediatric craniotomy: a retrospective study comparing the two stages of epilepsy surgery. Anesth Pain Med (Seoul) 2020; 15:283-290. [PMID: 33329826 PMCID: PMC7713839 DOI: 10.17085/apm.20010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022] Open
Abstract
Background During pediatric epilepsy surgery, due to low circulating blood volume, intraoperative bleeding can result in significant hemodynamic instability, thereby requiring meticulous hemodynamic and transfusion strategies. Knowing the source of bleeding during the procedure would allow medical staff to better prepare the perioperative protocols for these patients. We compared intraoperative bleeding between the first (involving skin to meninges) and second (involving brain parenchyma) stages of epilepsy surgery to investigate the differences between various anatomical sites. Methods We reviewed the electronic medical records of 102 pediatric patients < 14 years old who underwent two-stage epilepsy surgeries during January 2012–December 2016. Invasive subdural grids were placed via craniotomy during Stage 1 and the epileptogenic zone was removed during Stage 2 of the surgery. We compared the volume of intraoperative bleeding between these two surgeries and identified variables associated with bleeding using multivariate regression analysis. Results Both surgeries resulted in similar intraoperative bleeding (24 vs. 26 ml/kg, P = 0.835), but Stage 2 required greater volumes of blood transfusion than Stage 1 (18.4 vs. 14.8 ml/kg, P = 0.011). Massive bleeding was associated with patients < 7 years of age in Stage 1 and weighing < 18 kg in Stage 2. Conclusions The volume of intraoperative bleeding was similar between the two stages of pediatric epilepsy surgery and was large enough to require blood transfusions. Thus, blood loss during pediatric epilepsy surgery occurred at both anatomic sites. This indicates the necessity of early preparation for blood transfusion in both stages of pediatric epilepsy surgery.
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Affiliation(s)
- Bora Lee
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Myung Il Bae
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Darhae Eum
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Abel Mussa Ntungi
- Department of Anesthesiology, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, United Republic of Tanzania
| | - Byongnam Jun
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyeong Tae Min
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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12
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Effects of the ketogenic diet on platelet counts and global coagulation tests in childhood epilepsy. Seizure 2020; 80:31-37. [PMID: 32512283 DOI: 10.1016/j.seizure.2020.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Several antiseizure drugs (ASD), especially Valproic acid (VPA), influence platelet counts and coagulation parameters. The ketogenic diet (KD), established in drug-resistant epilepsy, is combined with ASDs. Bruising and prolonged bleeding times during KD have been described, but whether hemostatic changes result from the KD or from concomitant ASDs, remains unclear. Aim of the present study was to evaluate bleeding, platelet counts and global coagulation tests prior to and during KD in childhood epilepsy. METHOD Consecutive children treated with KD were systematically observed for bleeding. Serial measurements of platelet counts and global coagulation tests (APTT, PT and fibrinogen) were obtained at baseline and during KD (at 1, 3, 6 and 12 months). Children with KD monotherapy, concomitant VPA, or other ASDs were compared. RESULTS Among 162 children receiving KD, we observed neither bleeding in daily life nor perioperative bleeding in those undergoing surgery (n = 25). Most children had normal platelet counts and coagulation parameters. Only a few had transient mild thrombocytopenia and mildly prolonged APTT values, not indicative of a bleeding risk. Even KD combined with VPA did not cause relevant coagulopathy. Unexpectedly, we found mild thrombocytosis in 24 % of patients prior to KD, which was most pronounced in yet untreated epilepsy. Thrombocytosis steadily resolved during KD. CONCLUSIONS During KD treatment of childhood epilepsy, we observed neither bleeding symptoms nor laboratory results indicating a bleeding risk. Unexpectedly, mild thrombocytosis was present in 24 % at baseline, normalising during KD. Thrombocytosis may reflect the underlying inflammatory process of untreated epilepsy and requires further study.
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Kim DW, Kim W, Lee CH, Chun YI. Thrombocytopenia during intravenous valproic acid therapy in the neurological intensive care unit. J Clin Pharm Ther 2020; 45:1014-1020. [PMID: 32040242 DOI: 10.1111/jcpt.13125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/17/2019] [Accepted: 01/07/2020] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Thrombocytopenia is a common laboratory abnormality among critically ill patients under neurological intensive care unit (NCU) care. Valproic acid (VPA), a widely used antiepileptic drug, is one of the common causes of drug-induced thrombocytopenia. The purpose of this study was to estimate the incidence and risk factors of thrombocytopenia after intravenous VPA therapy among the patients admitted to NCU. METHODS We retrospectively reviewed the medical records of patients who were treated with intravenous VPA during their NCU stay between January 2014 and December 2018. We studied the frequency of thrombocytopenia and further evaluated the risk of thrombocytopenia in these patients. RESULTS Among the 283 patients (181 male [64.0%], mean age: [61.0 ± 14.9] years) who were treated with intravenous VPA, thrombocytopenia was observed in 104 patients (36.7%). Thrombocytopenia was associated with several risk factors, including lower baseline platelet counts (<200 × 109 /L); aetiologies other than intracranial or subarachnoid haemorrhage; longer use of VPA (more than 3 days); higher daily dose of VPA (more than 1000 mg/d); concurrent use of VPA with other antiepileptic drugs; infection; and the use of mechanical ventilation. Multivariate analysis found several independent risk factors of thrombocytopenia with intravenous VPA therapy, including lower baseline platelet counts, aetiologies other than intracranial or subarachnoid haemorrhage, use of VPA for more than 3 days and infection. WHAT IS NEW AND CONCLUSION Thrombocytopenia is common in NCU patients. Because several clinical and laboratory factors are associated with thrombocytopenia, careful use of VPA should be considered in patients with these risk factors.
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Affiliation(s)
- Dong Wook Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, South Korea
| | - Wonshik Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, South Korea
| | - Chang-Hoon Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Young Il Chun
- Department of Neurosurgery, Konkuk University School of Medicine, Seoul, South Korea
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14
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Al Ghamdi RM, Turkistani AN, Ben Ali H. Phenytoin Seizure Prophylaxis Therapy Resulting in Severe Thrombocytopenia After Brain Tumor Debulking Surgery. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e919828. [PMID: 31996666 PMCID: PMC7006599 DOI: 10.12659/ajcr.919828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patient: Male, 40-year-old Final Diagnosis: Phenytoin-induced thrombocytopenia Symptoms: Thrombocytopenia Medication: Phenytoin Clinical Procedure: Tumor debulking surgery Specialty: Neurosurgery
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Affiliation(s)
- Rawan M Al Ghamdi
- Department of Pharmacy, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Alaa N Turkistani
- Department of Neurosurgery, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Haitham Ben Ali
- Department of Neurosurgery, King Fahad Specialist Hospital, Dammam, Saudi Arabia
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Abstract
More than one-third of patients with meningiomas will experience seizures at some point in their disease. Despite this, meningioma-associated epilepsy remains significantly understudied, as most investigations focus on tumor progression, extent of resection, and survival. Due to the impact of epilepsy on the patient's quality of life, identifying predictors of preoperative seizures and postoperative seizure freedom is critical. In this chapter, we review previously reported rates and predictors of seizures in meningioma and discuss surgical and medical treatment options. Preoperative epilepsy occurs in approximately 30% of meningioma patients with peritumoral edema on neuroimaging being one of the most significant predictor of seizures. Other associated factors include age <18, male gender, the absence of headache, and non-skull base tumor location. Following tumor resection, approximately 70% of individuals with preoperative epilepsy achieve seizure freedom. Variables associated with persistent seizures include a history of preoperative epilepsy, peritumoral edema, skull base tumor location, tumor progression, and epileptiform discharges on postoperative electroencephalogram. In addition, after surgery, approximately 10% of meningioma patients without preoperative epilepsy experience new seizures. Variables associated with new postoperative seizures include tumor progression, prior radiation exposure, and gross total tumor resection. Both pre- and postoperative meningioma-related seizures are often responsive to antiepileptic drugs (AEDs), although AED prophylaxis in the absence of seizures is not recommended. AED selection is based on current guidelines for treating focal seizures with additional considerations including efficacy in tumor-related epilepsy, toxicities, and potential drug-drug interactions. Continued investigation into medical and surgical strategies for preventing and alleviating epilepsy in meningioma is warranted.
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Affiliation(s)
- Stephen C Harward
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, United States
| | - John D Rolston
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, United States
| | - Dario J Englot
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, United States.
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Fujimoto A, Okanishi T, Sato K, Masuda Y, Nishimura M, Homma Y, Enoki H. Activities of daily living are associated with outcomes of epilepsy treatment in elderly patients. Psychogeriatrics 2020; 20:104-110. [PMID: 31060106 DOI: 10.1111/psyg.12463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 04/07/2019] [Accepted: 04/10/2019] [Indexed: 11/30/2022]
Abstract
AIM Controlling epileptic seizures in elderly populations is widely considered to be relatively easy, but we hypothesized that the lifestyles of elderly individuals may affect the outcomes of epilepsy treatment. The purpose of this study was to review the activities of daily living (ADL) of elderly individuals with epilepsy and compare them with the outcomes of epilepsy treatment. METHODS Of the 177 patients ≥65 years old who were referred to our epilepsy centre, epilepsy was diagnosed in 84. ADL and treatment outcomes were then reviewed, with ADL classified into three levels: ADL I, without disability; ADL II, disabled only in some instrumental ADL; and ADL III, disabled in some basic ADL. Epilepsy syndromes and use of anti-seizure drugs were also evaluated. RESULTS Forty-five patients (53.6%) achieved freedom from seizures, 23 (27.4%) achieved ≥80% but <100% reduction in seizures, 5 (6%) achieved ≥50% but <80% reduction in seizures, and 11 (13.1%) achieved <50% reduction in seizures. Thirty-five patients (81.4%) with ADL I achieved freedom from seizures, compared with seven patients with ADL II (28.0%) and three patients with ADL III (19.0%). A significant difference was evident among the three groups (F = 6.145, P = 0.003). CONCLUSIONS ADL should be taken into account when an epilepsy treatment is being selected.
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Affiliation(s)
- Ayataka Fujimoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamastsu, Japan
| | - Tohru Okanishi
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamastsu, Japan
| | - Keishiro Sato
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamastsu, Japan
| | - Yosuke Masuda
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamastsu, Japan
| | - Mitsuyo Nishimura
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamastsu, Japan
| | - Yoichiro Homma
- Department of General Internal Medicine, Seirei Hamamatsu General Hospital, Hamamastsu, Japan
| | - Hideo Enoki
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamastsu, Japan
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Kumar R, Vidaurre J, Gedela S. Valproic Acid-Induced Coagulopathy. Pediatr Neurol 2019; 98:25-30. [PMID: 31201069 DOI: 10.1016/j.pediatrneurol.2019.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 04/21/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Valproic acid is one of the most commonly used antiseizure medications. Multiple hematologic abnormalities have been reported with the use of valproic acid, which may be particularly relevant in the perioperative surgical setting. The incidence of these abnormalities and prevalence of periprocedural hemorrhage vary significantly in the published literature. In this article we analyze the prevalence and possible etiology of coagulopathy and hemorrhage in patients receiving valproic acid. METHODS A literature search was completed using "VPA," "coagulopathy," and "surgery." The available published data from case reports to large case series were reviewed. RESULTS Thrombocytopenia was noted to be the most common laboratory abnormality associated with valproic acid. An association between valproic acid and acquired von Willebrand disease has also been suggested. There are case reports describing bleeding in the setting of hypofibrinogenemia and factor XIII deficiency. Perioperative hemorrhage was reported in pediatric studies of orthopedic procedures, but not in adult cohorts undergoing neurosurgical interventions. CONCLUSIONS VPA use can cause thrombocytopenia and other coagulation abnormalities. Rigorous, prospective trials are needed to better assess the association between valproic acid and clinically significant coagulopathy. Until such data are available, physicians need to be aware of the potential risk of bleeding in patients receiving valproic acid. A hemostatic evaluation should be considered in symptomatic patients, and may be considered for patients taking VPA who are scheduled for surgery. If an abnormality is detected, hematologists should be involved to make recommendation on perioperative hemostatic strategy.
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Affiliation(s)
- Riten Kumar
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Jorge Vidaurre
- Department of Pediatrics, The Ohio State University, Columbus, Ohio; Division of Pediatric Neurology, Nationwide Children's Hospital, Columbus, Ohio
| | - Satyanarayana Gedela
- Department of Pediatrics, The Ohio State University, Columbus, Ohio; Division of Pediatric Neurology, Nationwide Children's Hospital, Columbus, Ohio.
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Reed MJ, Comeau S, Wojtanowicz TR, Sampathi BR, Penev S, Bota R. Case report: Chlorpromazine and deep venous thrombosis. Ment Illn 2019; 11:16-19. [PMID: 32742621 PMCID: PMC7364570 DOI: 10.1108/mij-10-2019-0005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose Since the development of antipsychotic drugs in the 1950s, a variety of studies and case reports have been published that suggest an association between exposure to typical antipsychotics and venous thromboembolisms (VTE). Therefore, when starting treatment with antipsychotics, especially low-potency typical antipsychotics and clozapine, health-care providers must account for the patient's existing VTE risk factors. Design/methodology/approach In this case report, the authors describe the development of a pulmonary embolism associated with use of chlorpromazine in the treatment of an acute manic episode in a 51-year-old female patient with bipolar disorder type 1. Findings The patient was brought to the emergency room by the police on a legal hold for bizarre behaviors at a bus stop, which included incessantly yelling at bystanders. The patient was found to have disorganized thoughts, poor sleep, rapid speech, labile mood, distractibility, auditory hallucinations and grandiose delusions. During the course of her stay, the patient received extensive IM chlorpromazine for extreme agitation, in addition to chlorpromazine 200 mg IM Q8H, which was later decreased to chlorpromazine 100 mg chlorpromazine IM/PO Q8H. On day 4 of the treatment, the patient experienced difficulty breathing, hypoxia and tachycardia and was found to have bilateral expiratory wheezes. CT angiography showed sub-segmental pulmonary embolus and the patient was transferred to MICU service. The patient was then intubated and started on heparin by the medical team. Over the course of the next day, her respiratory distress resolved and the patient was extubated. Originality/value It is possible that chlorpromazine may indeed increase VTEs, and there are various physiological postulations regarding the mechanism of action. However, multiple confounding variables existed in the authors' report, including venous stasis and the use of restraints, tobacco and valproic acid. Each of these variables has been shown to increase VTE occurrence. Further controlled studies are necessary to identify the true relationship between antipsychotics and VTEs.
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Affiliation(s)
| | - Sean Comeau
- Department of Psychiatry, University of California, Irvine, California, USA
| | | | | | - Sofia Penev
- Department of Psychiatry, University of California, Irvine, California, USA
| | - Robert Bota
- Department of Psychiatry, University of California, Irvine, California, USA
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Verrotti A, Striano P, Iapadre G, Zagaroli L, Bonanni P, Coppola G, Elia M, Mecarelli O, Franzoni E, Liso PD, Vigevano F, Curatolo P. The pharmacological management of Lennox-Gastaut syndrome and critical literature review. Seizure 2018; 63:17-25. [DOI: 10.1016/j.seizure.2018.10.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/11/2018] [Accepted: 10/25/2018] [Indexed: 12/29/2022] Open
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Iapadre G, Balagura G, Zagaroli L, Striano P, Verrotti A. Pharmacokinetics and Drug Interaction of Antiepileptic Drugs in Children and Adolescents. Paediatr Drugs 2018; 20:429-453. [PMID: 30003498 DOI: 10.1007/s40272-018-0302-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Selecting the most appropriate antiepileptic drug (AED) or combination of drugs for each patient and identifying the most suitable therapeutic regimen for their needs is increasingly challenging, especially among pediatric populations. In fact, the pharmacokinetics of several drugs vary widely in children with epilepsy because of age-related factors, which can influence the absorption, distribution, metabolism, and elimination of the pharmacological agent. In addition, individual factors, such as seizure type, associated comorbidities, individual pharmacokinetics, and potential drug interactions, may contribute to large fluctuations in serum drug concentrations and, therefore, clinical response. Therapeutic drug concentration monitoring (TDM) is an essential tool to deal with this complexity, enabling the definition of individual therapeutic concentrations and adaptive control of dosing to minimize drug interactions and prevent loss of efficacy or toxicity. Moreover, pharmacokinetic/pharmacodynamic modelling integrated with dashboard systems have recently been tested in antiepileptic therapy, although more clinical trials are required to support their use in clinical practice. We review the mechanism of action, pharmacokinetics, drug-drug interactions, and safety/tolerability profiles of the main AEDs currently used in children and adolescents, paying particular regard to issues of relevance when treating this patient population. Indications for TDM are provided for each AED as useful support to the clinical management of pediatric patients with epilepsy by optimizing pharmacological therapy.
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Affiliation(s)
- Giulia Iapadre
- Department of Pediatrics, University of L'Aquila, Via Vetoio, 1. Coppito, L'Aquila, Italy
| | - Ganna Balagura
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Opthalmology, Genetics, Maternal and Child Health, University of Genoa, "G. Gaslini" Institute, Genoa, Italy
| | - Luca Zagaroli
- Department of Pediatrics, University of L'Aquila, Via Vetoio, 1. Coppito, L'Aquila, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Opthalmology, Genetics, Maternal and Child Health, University of Genoa, "G. Gaslini" Institute, Genoa, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, Via Vetoio, 1. Coppito, L'Aquila, Italy.
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Haas T, Cushing MM, Varga S, Gilloz S, Schmugge M. Usefulness of multiple electrode aggregometry as a screening tool for bleeding disorders in a pediatric hospital. Platelets 2018; 30:498-505. [DOI: 10.1080/09537104.2018.1475631] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Thorsten Haas
- Department of Anesthesia, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Melissa M. Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Stephanie Varga
- Department of Anesthesia, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Séverine Gilloz
- Department of Hematology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Markus Schmugge
- Department of Hematology, University Children’s Hospital Zurich, Zurich, Switzerland
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Abstract
PURPOSE OF REVIEW Status epilepticus (SE) is a multisystem disorder. Initially, complications of a massive catecholamine release followed by the side effects of medical therapies, impact patients' outcomes. The aim of this article is to provide an updated summary of the systemic complications following SE. RECENT FINDINGS In recent years, the importance of the multifaceted nature of SE and its relationship with clinical outcomes has been increasingly recognized. The cumulative systemic effects of prolonged seizures and their treatment contribute to morbidity and mortality in this condition. Most systemic complications after SE are predictable. Anticipating their occurrence and respecting a number of simple guidelines may improve the prognosis of these patients.
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Affiliation(s)
- Maximiliano A Hawkes
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
| | - Sara E Hocker
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
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Dispensability of Annual Laboratory Follow-Up After More than 2 Years of Valproic Acid Use: A Systematic Review. CNS Drugs 2017; 31:939-957. [PMID: 29214384 DOI: 10.1007/s40263-017-0479-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The necessity of annual laboratory follow-up in patients treated with valproic acid (VPA) is controversial. OBJECTIVE We investigated the need for annual laboratory follow-up of liver enzymes, electrolytes, and full blood count (FBC) in patients treated with VPA. PATIENTS AND METHODS A systematic search in Evidence-Based Medicine Reviews (EBMR), MEDLINE, and EMBASE was undertaken in December 2016 to identify all published articles investigating or citing valproic acid, liver function disorders, electrolyte disorders, and FBC deviations. RESULTS This review included 108 articles. As the number of participants and duration of the study was not adequate in most studies to detect rare adverse events, studies did not demonstrate a clear prevalence of hepatotoxicity. While a transient increase of transaminases is common and seldom harmful, severe hepatotoxicity is a rare phenomenon and is not prevented by routine laboratory monitoring. VPA had no relevant effect on serum calcium, sodium, potassium, and albumin. The prevalence of FBC varied from 0.6 to 27.8%, occurred mostly in the first 2 years of therapy, and was usually asymptomatic. CONCLUSIONS Long-term monitoring in VPA treatment is only necessary when there have been dose adjustments, co-medication switches, or co-morbidity. In uncomplicated cases, annual laboratory follow-up may be discontinued after 2 years of VPA treatment. Encouraging patients to be vigilant is more effective in the detection of hepatotoxicity than laboratory testing. Follow-up of FBC at 3-6 months, 1 year, and 2 years after start or after a dose increase of VPA or interacting medication is sufficient.
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Hebert SA, Bohan TP, Erikson CL, Swinford RD. Thrombotic microangiopathy associated with Valproic acid toxicity. BMC Nephrol 2017; 18:262. [PMID: 28774273 PMCID: PMC5543430 DOI: 10.1186/s12882-017-0677-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/26/2017] [Indexed: 12/18/2022] Open
Abstract
Background Thrombotic microangiopathy (TMA) is a serious, sometimes life-threatening disorder marked by the presence of endothelial injury and microvascular thrombi. Drug-induced thrombotic microangiopathy (DI-TMA) is one specific TMA syndrome that occurs following drug exposure via drug-dependent antibodies or direct tissue toxicity. Common examples include calcineurin inhibitors Tacrolimus and Cyclosporine and antineoplastics Gemcitabine and Mitomycin. Valproic acid has not been implicated in DI-TMA. We present the first case of a patient meeting clinical criteria for DI-TMA following admission for valproic acid toxicity. Case presentation An adolescent male with difficult to control epilepsy was admitted for impaired hepatic function while on valproic acid therapy. On the third hospital day, he developed severe metabolic lactic acidosis and multiorgan failure, prompting transfer to the pediatric intensive care unit. Progressive anemia and thrombocytopenia instigated an evaluation for thrombotic microangiopathy, where confirmed by concomitant hemolysis, elevated lactate dehydrogenase (LDH), low haptoglobin, and concurrent oliguric acute kidney injury. Thrombotic thrombocytopenic purpura was less likely with adequate ADAMTS13. Discontinuing valproic acid reversed the anemia, thrombocytopenia, and normalized the LDH and haptoglobin, supporting a drug-induced cause for the TMA. Conclusion To the best of our knowledge, this is the first report of drug-induced TMA from valproic acid toxicity.
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Affiliation(s)
- Sean A Hebert
- Department of Internal Medicine and Pediatrics, Division of Nephrology, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Children's Memorial Hermann Hospital, 6431 Fannin Street, MSB 3.121, Houston, TX, USA.
| | - Timothy P Bohan
- Pediatric Neurology, Memorial Hermann Texas Medical Center, Children's Memorial Hermann Hospital, 6400 Fannin Street, Ste 2740, Houston, TX, USA
| | - Christian L Erikson
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital, The Woodlands 17600 I-45 South, WL 640, Conroe, TX, USA
| | - Rita D Swinford
- Department of Pediatrics, Division of Nephrology, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Children's Memorial Hermann Hospital, 6431 Fannin Street, MSB 3. 121, Houston, TX, USA
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Kurwale N, Garg K, Arora A, Chandra PS, Tripathi M. Valproic acid as an antiepileptic drug: Is there a clinical relevance for the epilepsy surgeon? Epilepsy Res 2016; 127:191-194. [PMID: 27610748 DOI: 10.1016/j.eplepsyres.2016.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 02/18/2016] [Accepted: 09/03/2016] [Indexed: 10/21/2022]
Abstract
Valproic acid (VPA) has been associated with coagulation factors deficiency, platelet dysfunction and hemorrhagic complications. We investigated 169 patients with drug resistant epilepsy (DRE), who underwent surgery, to look for clinical implications of VPA associated bleeding problems. All patients had normal preoperative coagulation profile. VPA was a part of polytherapy in 54% of patients (Group A), however 46% patients were not on VPA (Group B). The groups were comparable with mean age of 17.3±10.3years. Mean duration of surgery in group A and B were 255±70 and 250±60min respectively (p=0.26). Average blood loss in group A was 399±254 and 389±228ml in group B. (p=0.62). The percentage of total blood volume lost was 12.7% (Group A) and 17.7% (Group B) respectively (p=0.7). There were no bleeding complications in either group. Hyperammonemic encephalopathy occurred in 4 patients postoperateively requiring withdrawal or dose reduction of VPA. No mortality was recorded. We conclude that VPA does not increase clinically relevant perioperative haemorrhagic complications in patients having normal coagulation screen and platelet counts. However, hyperammonemic encephalopathy is observed in 4% of patients in perioperative period, favorably responding to discontinuation of VPA.
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Xiao W, Fu W, Wang T, Zhao L. Prophylactic use of tranexamic acid combined with thrombelastogram guided coagulation management may reduce blood loss and allogeneic transfusion in pediatric hemispherectomy: case series. J Clin Anesth 2016; 33:149-55. [DOI: 10.1016/j.jclinane.2016.02.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 01/29/2016] [Accepted: 02/18/2016] [Indexed: 10/21/2022]
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Fröscher W, Kirschstein T, Rösche J. Anticonvulsant therapy in brain-tumor related epilepsy. JOURNAL OF EPILEPTOLOGY 2016. [DOI: 10.1515/joepi-2016-0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
SummaryBackground. The lifetime risk of patients with brain tumors to have focal epileptic seizures is 10-100%; the risk depends on different histology. Specific guidelines for drug treatment of brain tumor-related seizures have not yet been established.Aim. This review addresses the special aspects of antiepileptic drug (AED) therapy in brain tumor-related epilepsy.Methods. We analyzed the literature up to December 2015.Results. Based on current evidence the management of tumor-related seizures does not differ substantially from that applied to epilepsies from other etiologies. Therefore, the choice of an AED is based, above all, on tolerability and pharmacokinetic interactions with chemotherapeutic drugs. Levetiracetam is recommended by many authors as first-line therapy in brain tumor-related epilepsy. Due to the possibility of interactions, the combination of enzyme-inducing AEDs and chemotherapeutic drugs, is usually not recommended as a first choice. Currently there is no evidence that prophylactic prescription of long-term AEDs in brain tumor-patients who did not present with seizures is justified. Because of the high risk of recurrence, however, AED treatment should be strongly considered after a single brain tumor-related seizure. The decision to withdraw AEDs must carefully consider the risk of seizure recurrence.Conclusion. At present levetiracetam is the preferred drug in brain tumor-related epilepsy, especially when drug interactions need to be avoided. In the future we hope to acquire more targeted drugs against this disorder by uncovering its pathogenesis.
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Huberfeld G, Vecht CJ. Seizures and gliomas — towards a single therapeutic approach. Nat Rev Neurol 2016; 12:204-16. [DOI: 10.1038/nrneurol.2016.26] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Cukiert A, Rydenhag B, Harkness W, Cross JH, Gaillard WD. Technical aspects of pediatric epilepsy surgery: Report of a multicenter, multinational web-based survey by the ILAE Task Force on Pediatric Epilepsy Surgery. Epilepsia 2016; 57:194-200. [DOI: 10.1111/epi.13292] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Arthur Cukiert
- Department of Neurosurgery; ABC Faculty of Medicine; Sao Paulo Brazil
| | - Bertil Rydenhag
- Institute of Neuroscience and Physiology; Sahlgrenska Academy of Gothenburg University; Gothenburg Sweden
- Department of Neurosurgery; Sahlgrenska University Hospital; Gothenburg Sweden
| | - William Harkness
- Department of Neurosurgery; Great Ormond Street Hospital for Children NHS Foundation Trust; London United Kingdom
| | - 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
| | - William D. Gaillard
- Center for Neuroscience and Behavioral Health; Children's National Health System; The George Washington University School of Medicine and Health Sciences; Washington District of Columbia U.S.A
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Abstract
Seizures are common in patients with brain tumors, and epilepsy can significantly impact patient quality of life. Therefore, a thorough understanding of rates and predictors of seizures, and the likelihood of seizure freedom after resection, is critical in the treatment of brain tumors. Among all tumor types, seizures are most common with glioneuronal tumors (70-80%), particularly in patients with frontotemporal or insular lesions. Seizures are also common in individuals with glioma, with the highest rates of epilepsy (60-75%) observed in patients with low-grade gliomas located in superficial cortical or insular regions. Approximately 20-50% of patients with meningioma and 20-35% of those with brain metastases also suffer from seizures. After tumor resection, approximately 60-90% are rendered seizure-free, with most favorable seizure outcomes seen in individuals with glioneuronal tumors. Gross total resection, earlier surgical therapy, and a lack of generalized seizures are common predictors of a favorable seizure outcome. With regard to anticonvulsant medication selection, evidence-based guidelines for the treatment of focal epilepsy should be followed, and individual patient factors should also be considered, including patient age, sex, organ dysfunction, comorbidity, or cotherapy. As concomitant chemotherapy commonly forms an essential part of glioma treatment, enzyme-inducing anticonvulsants should be avoided when possible. Seizure freedom is the ultimate goal in the treatment of brain tumor patients with epilepsy, given the adverse effects of seizures on quality of life.
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Affiliation(s)
- Dario J Englot
- UCSF Comprehensive Epilepsy Center, University of California San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Edward F Chang
- UCSF Comprehensive Epilepsy Center, University of California San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Charles J Vecht
- Service Neurologie Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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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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Alford EL, Wheless JW, Phelps SJ. Treatment of Generalized Convulsive Status Epilepticus in Pediatric Patients. J Pediatr Pharmacol Ther 2015; 20:260-89. [PMID: 26380568 PMCID: PMC4557718 DOI: 10.5863/1551-6776-20.4.260] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Generalized convulsive status epilepticus (GCSE) is one of the most common neurologic emergencies and can be associated with significant morbidity and mortality if not treated promptly and aggressively. Management of GCSE is staged and generally involves the use of life support measures, identification and management of underlying causes, and rapid initiation of anticonvulsants. The purpose of this article is to review and evaluate published reports regarding the treatment of impending, established, refractory, and super-refractory GCSE in pediatric patients.
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Affiliation(s)
- Elizabeth L. Alford
- Department of Clinical Pharmacy, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Center for Pediatric Pharmacokinetics and Therapeutics, Memphis, Tennessee
| | - James W. Wheless
- Departments of Pediatrics, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
- Pediatric Neurology, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
- Le Bonheur Neuroscience Center and Comprehensive Epilepsy Program, Memphis, Tennessee
| | - Stephanie J. Phelps
- Department of Clinical Pharmacy, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Center for Pediatric Pharmacokinetics and Therapeutics, Memphis, Tennessee
- Departments of Pediatrics, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
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Inzirillo F, Giorgetta C, Ravalli E, Pona CD. Diffuse alveolar hemorrhage due to valproic acid: Case report and review of the literature. Lung India 2015; 32:175-7. [PMID: 25814807 PMCID: PMC4372876 DOI: 10.4103/0970-2113.152646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Valproic acid (VPA) is one of the most frequently used antiepileptic drugs for the treatment of focal and generalized epilepsies, absence seizures, and Lennox-Gastaut syndrome (LGS). VPA has been demonstrated to have a negative effect on both the intrinsic and extrinsic coagulation systems and controversy exists about the clinical relevance of such hematological abnormalities. We describe a case of reversible lung hemorrage due to VPA. In English-language literature only two other similar cases (one of which fatal) have been described so far.
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Affiliation(s)
| | | | - Eugenio Ravalli
- Department of Thoracic Surgery, Morelli Hospital, AOVV, Sondalo, Italy
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Trécul A, Morceau F, Gaigneaux A, Schnekenburger M, Dicato M, Diederich M. Valproic acid regulates erythro-megakaryocytic differentiation through the modulation of transcription factors and microRNA regulatory micro-networks. Biochem Pharmacol 2014; 92:299-311. [DOI: 10.1016/j.bcp.2014.07.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 07/10/2014] [Accepted: 07/14/2014] [Indexed: 10/24/2022]
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Star K, Edwards IR, Choonara I. Valproic acid and fatalities in children: a review of individual case safety reports in VigiBase. PLoS One 2014; 9:e108970. [PMID: 25302991 PMCID: PMC4193865 DOI: 10.1371/journal.pone.0108970] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 09/02/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Valproic acid is an effective first line drug for the treatment of epilepsy. Hepatotoxicity is a rare and potentially fatal adverse reaction for this medicine. OBJECTIVE Firstly to characterise valproic acid reports on children with fatal outcome and secondly to determine reporting over time of hepatotoxicity with fatal outcome. METHODS Individual case safety reports (ICSRs) for children ≤ 17 years with valproic acid and fatal outcome were retrieved from the WHO Global ICSR database, VigiBase, in June 2013. Reports were classified into hepatotoxic reactions or other reactions. Shrinkage observed-to-expected ratios were used to explore the relative reporting trend over time and for patient age. The frequency of polytherapy, i.e. reports with more than one antiepileptic medicine, was investigated. RESULTS There have been 268 ICSRs with valproic acid and fatal outcome in children, reported from 25 countries since 1977. A total of 156 fatalities were reported with hepatotoxicity, which has been continuously and disproportionally reported over time. There were 31 fatalities with pancreatitis. Other frequently reported events were coma/encephalopathy, seizures, respiratory disorders and coagulopathy. Hepatotoxicity was disproportionally and most commonly reported in children aged 6 years and under (104/156 reports) but affected children of all ages. Polytherapy was significantly more frequently reported for valproic acid with fatal outcome (58%) compared with non-fatal outcome (34%). CONCLUSION Hepatotoxicity remains a considerable problem. The risk appears to be greatest in young children (6 years and below) but can occur at any age. Polytherapy is commonly reported and seems to be a risk factor for hepatotoxicity, pancreatitis and other serious adverse drug reactions with valproic acid.
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Affiliation(s)
- Kristina Star
- Uppsala Monitoring Centre, WHO Collaborating Centre for International Drug Monitoring, Uppsala, Sweden
- * E-mail:
| | - I. Ralph Edwards
- Uppsala Monitoring Centre, WHO Collaborating Centre for International Drug Monitoring, Uppsala, Sweden
| | - Imti Choonara
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Nottingham, United Kingdom
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Katsiki N, Mikhailidis DP, Nair DR. The effects of antiepileptic drugs on vascular risk factors: A narrative review. Seizure 2014; 23:677-84. [DOI: 10.1016/j.seizure.2014.05.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 05/21/2014] [Accepted: 05/24/2014] [Indexed: 12/13/2022] Open
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Thudium MO, von Lehe M, Wessling C, Schoene-Bake JC, Soehle M. Safety, feasibility and complications during resective pediatric epilepsy surgery: a retrospective analysis. BMC Anesthesiol 2014; 14:71. [PMID: 25157215 PMCID: PMC4142256 DOI: 10.1186/1471-2253-14-71] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 08/13/2014] [Indexed: 02/08/2023] Open
Abstract
Background Resective epilepsy surgery is an established and effective method to reduce seizure burden in drug-resistant epilepsy. It was the objective of this study to assess intraoperative blood loss, transfusion requirements and the degree of hypothermia of pediatric epilepsy surgery in our center. Methods Patients were identified by our epilepsy surgery database, and data were collected via retrospective chart review over the past 25 years. Patients up to the age of 6 years were included, and patients with insufficient data were excluded. Results Forty-five patients with an age of 3.2 ± 1.6 (mean ± SD) years and a body weight of 17 [14; 21.5] kg (median [25%, 75% percentile]) were analysed. Duration of surgery was 3 h 49 min ± 53 min, which was accompanied by an intraoperative blood loss of 150 [90; 300] ml. This corresponded to 11.7 [5.2; 21.4] % of estimated total blood volume, ranging from 0 to 75%. A minimal haemoglobin count of 8.8 ± 1.4 g/dl was measured, which was substituted with erythrocyte concentrate (100 [0; 250] ml) in 23 patients. Body core temperature dropped from 36.0 ± 0.7°C at baseline to a minimum of 35.7 ± 0.7°C, and increased significantly (p < 0.001) thereafter to 37.1 ± 0.7°C until the end of surgery. A significant (p = 0.0003) correlation between duration of surgery and blood loss (Pearson r = 0.52) was observed. However, age, minimal body temperature or number of antiepileptic drugs seemed to have no impact on blood loss. Conclusion Resective epilepsy surgery is a safe procedure even in the pediatric population, however it is associated with significant blood loss especially during long surgical procedures.
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Affiliation(s)
- Marcus O Thudium
- Department of Anesthesiology and Intensive Care Medicine, Sigmund-Freud-Str. 25, 53105 Bonn, Germany
| | - Marec von Lehe
- Department of Neurosurgery, University of Bochum, Knappschaftskrankenhaus, In der Schornau 23-25, 44892 Bochum, Germany
| | - Caroline Wessling
- Department of Neurosurgery, Sigmund-Freud-Str. 25, 53105 Bonn, Germany
| | - Jan-Christoph Schoene-Bake
- Department of Pediatrics, University of Freiburg Medical Center, Heiliggeiststraße 1, 79106 Freiburg im Breisgau, Germany
| | - Martin Soehle
- Department of Anesthesiology and Intensive Care Medicine, Sigmund-Freud-Str. 25, 53105 Bonn, Germany
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Abdallah C. Considerations in perioperative assessment of valproic acid coagulopathy. J Anaesthesiol Clin Pharmacol 2014; 30:7-9. [PMID: 24574585 PMCID: PMC3927296 DOI: 10.4103/0970-9185.125685] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Valproic acid (VPA) is one of the widely prescribed antiepileptic drugs in children with multiple indications. VPA-induced coagulopathy may occur and constitute a pharmacological and practical challenge affecting pre-operative evaluation and management of patients receiving VPA therapy. This review summarizes the different studies documenting the incidence, severity and available recommendations related to this adverse effect.
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Affiliation(s)
- Claude Abdallah
- Department of Anesthesiology, Children's National Medical Center, The George Washington University Medical Center, NW Washington, DC, USA
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Verrotti A, Scaparrotta A, Grosso S, Chiarelli F, Coppola G. Anticonvulsant drugs and hematological disease. Neurol Sci 2014; 35:983-93. [PMID: 24619070 DOI: 10.1007/s10072-014-1701-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 02/24/2014] [Indexed: 10/25/2022]
Abstract
Many antiepileptic drugs (AEDs) are associated with hematological disorders that range from mild thrombocytopenia or neutropenia to anemia, red cell aplasia, until bone marrow failure. Fortunately, potentially fatal hematological disorders such as aplastic anemia are very rare. This review investigates hematological effects associated with classic and newer AEDs: a PubMed search indexed for MEDLINE was undertaken to identify studies in adults, children and animals using the name of all anticonvulsant drugs combined with the terms "hematological disease" and "hematological abnormalities" as key words. The most common hematological alterations occur with older AEDs than newer. Indeed, careful hematological monitoring is needed especially using carbamazepine, phenytoin and valproic acid. The pathogenetic mechanisms are still unknown: they seem to be related to an immunological mechanism, but drugs pharmacokinetics and pharmacodynamics interactions may also play an important role. Further research is needed to assess the real pathogenetic mechanism at the basis of hematological complications caused by AEDs.
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Affiliation(s)
- A Verrotti
- Department of Pediatrics, University of Perugia, Perugia, Italy,
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Abstract
Between 30% and 50% of patients with brain tumors first present with a seizure, and up to 30% more will develop seizures later. Therefore, optimal management of these patients requires a rational approach to the use of antiseizure medications. Based on current evidence, prophylactic prescription of long-term antiepileptic drugs (AEDs) in patients with brain tumors in patients who did not present with seizures is not justified. Because of the high risk of recurrence, however, AED treatment should be strongly considered after a single seizure considered to be due to a tumor. Because of the lack of well-controlled randomized trials, the decision on which AED provides the best risk-benefit ratio in the individual patient is based mostly on physician's judgment rather than sound scientific evidence. In patients who may require chemotherapy, a non-enzyme-inducing AED is preferred for initial treatment to minimize the risk of drug interactions that impact adversely on the outcome of anticancer chemotherapy. Several retrospective studies in seizure patients with glioblastoma treated with chemotherapy have provided evidence for a moderately improved survival with the use of valproic acid, possibly due to inhibition of histone deacetylase. However, valproic acid may also increase the hematologic toxicity of antineoplastic drugs, presumably by inhibiting their metabolism, and may independently impair hemostasis, which is of some concern for patients who require surgical intervention. Among newer generation AEDs, levetiracetam has a number of advantageous features, including availability of a parenteral formulation, but other agents such as gabapentin, lamotrigine, oxcarbazepine, topiramate, and zonisamide may also be considered. Potentially more effective treatments targeting specific mechanisms of epileptogenesis and ictogenesis are being investigated. Resection of the tumor, radiation therapy, or chemotherapy can bring refractory seizures under control or prolong the duration of seizure freedom, an effect that does not appear to be necessarily related to removal or shrinkage of the tumor mass. In patients with a successfully treated tumor and an overall good prognosis for long-term survival, gradual discontinuation of AEDs may be considered.
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Affiliation(s)
- Emilio Perucca
- Department of Internal Medicine and Therapeutics, University of Pavia and C Mondino National Neurological Institute, Pavia, Italy
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Davidson DC, Jackson JW, Maggirwar SB. Targeting platelet-derived soluble CD40 ligand: a new treatment strategy for HIV-associated neuroinflammation? J Neuroinflammation 2013; 10:144. [PMID: 24289660 PMCID: PMC3906985 DOI: 10.1186/1742-2094-10-144] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/16/2013] [Indexed: 11/17/2022] Open
Abstract
Human immunodeficiency virus type 1 (HIV) continues to be one of the most prevalent global health afflictions to date. The advent and introduction of combined antiretroviral therapy (cART) has made a significant impact on the course of infection. However, as patients are living longer, many HIV-associated illnesses are becoming prevalent among the infected population, especially those associated with chronic inflammation. Consistently, HIV-associated neuroinflammation is believed to be a major catalyst in the development of HIV-associated neurocognitive disorders (HAND), which are estimated to persist in approximately 50% of infected individuals regardless of cART. This dramatically underscores the need to develop effective adjunctive therapies capable of controlling this aspect of the disease, which are currently lacking. We previously demonstrated that the inflammatory mediator soluble CD40 ligand (sCD40L) is elevated in both the plasma and cerebrospinal fluid of cognitively impaired infected individuals compared to their non-impaired infected counterparts. Our group, and others have recently demonstrated that there is an increasing role for this inflammatory mediator in the pathogenesis of HIV-associated neuroinflammation, thereby identifying this molecule as a potential therapeutic target for the management of HAND. Platelets are the major source of circulating sCD40L, and these small cells are increasingly implicated in a multitude of inflammatory disorders, including those common during HIV infection. Thus, antiplatelet therapies that minimize the release of platelet-derived inflammatory mediators such as sCD40L are an innovative, non-traditional approach for the treatment of HIV-associated neuroinflammation, with the potential to benefit other HIV-associated illnesses.
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Affiliation(s)
| | | | - Sanjay B Maggirwar
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 672, Rochester, NY 14642, USA.
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Chen HF, Xu LP, Luo ZY, Yu ZQ, Li ZY, Cui QY, Qin LM, Ren YY, Shen HS, Tang JQ, Jin LJ, Zhu JJ, Wang J, Wang KY, Wu TQ, Wang ZY. Valproic acid-associated low fibrinogen and delayed intracranial hemorrhage: case report and mini literature review. DRUG DESIGN DEVELOPMENT AND THERAPY 2013; 7:767-70. [PMID: 23976844 PMCID: PMC3746782 DOI: 10.2147/dddt.s47718] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 41-year-old male had suffered from gradual hearing loss in his right ear for 2 years. Head computed tomography and magnetic resonance imaging scans showed a neoplasm in the cerebellopontine angle region, which was confirmed by the diagnosis of acoustic neurilemmoma by pathological findings after surgery. Following surgery, he routinely received valproic acid (VPA) to prevent seizures. However, the patient presented with hypofibrinogenemia and cerebral hemorrhage after taking VPA for 12 days. The hypofibrinogenemia recurred when VPA was re-administered. After withdrawal of VPA, his fibrinogen concentration rose to normal within several days. As far as we are aware, this is the first case of cerebral hemorrhage due to VPA to have been reported. Herein, as well as reporting on this case, a mini review of the relevant literature is also presented.
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Affiliation(s)
- Hai-Fei Chen
- Department of Hematology, 100th Hospital of People's Liberation Army, Suzhou, People's Republic of China
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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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Fajardo A, Olmos F, Sarmiento L. Valproic acid and the risk of perioperative bleeding. Case report and literature review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rcae.2012.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Ácido valproico y riesgo de sangrado perioperatorio. Reporte de caso y revisión de la literatura. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rca.2012.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Valproic acid and the risk of perioperative bleeding. Case report and literature review☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1097/01819236-201341010-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Stork CM, Marraffa JM, Ragosta K, Wojcik SM, Angelino KL. Elevated International Normalized Ratio associated with long-term azithromycin therapy in a child with cerebral palsy. Am J Health Syst Pharm 2011; 68:1012-4. [PMID: 21593229 DOI: 10.2146/ajhp100603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE A case of coagulopathy in a pre-adolescent with cerebral palsy that developed after chronic prophylactic antibiotic use is reported. SUMMARY An 11-year-old boy with cerebral palsy was brought to the emergency department experiencing restlessness and decreased oxygen saturation. Evaluation of the patient revealed gallstone-related pancreatitis, with elevated serum amylase and lipase concentrations and abnormal liver function test results. At the time of the initial evaluation, the International Normalized Ratio (INR) was 6.54 (normal range, 0.8-1.2), and the activated partial thromboplastin time was 53.8 seconds (normal range, 24.4-34.8 seconds). The boy's medication history included use of azithromycin 200 mg every other day for about two years for antiinflammatory therapy. On confirmation of the elevated INR 2 hours after the initial evaluation, azithromycin was discontinued, and a single dose of phytonadione 2 mg was administered. About 14 hours after phytonadione administration, the INR had declined to 0.94; 43 hours later, the INR remained within the normal range without further phytonadione therapy. Using the probability scale of Naranjo and colleagues, this case was rated as a probable drug-related adverse event. Previous reports have linked the development of vitamin K deficiency and impaired coagulation to long-term antibiotic use, but not specifically to use of azithromycin or other macrolide antibiotics. CONCLUSION An elevated INR in a child with cerebral palsy was evidently related to long-term therapy with azithromycin. The abnormal INR normalized after discontinuation of azithromycin and administration of one dose of phytonadione.
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Affiliation(s)
- Christine M Stork
- Departments of Emergency Medicine and Medicine, Upstate Medical University, Syracuse, NY
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The effect of antiepileptic drugs on coagulation and bleeding in the perioperative period of epilepsy surgery: The Cleveland Clinic experience. J Clin Neurosci 2011; 18:1180-4. [DOI: 10.1016/j.jocn.2011.02.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 02/27/2011] [Indexed: 11/22/2022]
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Brennan SO, Oliver J, Davis RL. Epigenetic, polymorphic and mutational (Αα167Arg→Lys) contribution to a functionally abnormal fibrinogen. J Thromb Haemost 2011; 9:1410-2. [PMID: 21605328 DOI: 10.1111/j.1538-7836.2011.04337.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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