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Molisani SE, Parikh D, DiGiovine M, Dlugos D, Fitzgerald MP, Fried L, Helbig I, Kessler SK, McDonnell PP, Melamed S, Prelack MS, Sharif U, Tefft S, Tencer J, Witzman S, Shaw K, Abend NS. A quality improvement initiative to improve folic acid supplementation counseling for adolescent females with epilepsy. Epilepsia 2023; 64:2818-2826. [PMID: 37496463 DOI: 10.1111/epi.17723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE We designed a quality improvement (QI) project to improve rates of documented folic acid supplementation counseling for adolescent females with epilepsy, consistent with a quality measure from the American Academy of Neurology and American Epilepsy Society. Our SMART aim was to increase the percentage of visits at which folic acid counseling was addressed from our baseline rate of 23% to 50% by July 1, 2020. METHODS This initiative was conducted in female patients ≥12 years old with epilepsy who were prescribed daily antiseizure medication and were seen by the 13 providers in our Neurology QI Program. Using provider interviews, we undertook a root cause analysis of low counseling rates and identified the following main factors: insufficient time during clinic visit to counsel, lack of provider knowledge, and forgetting to counsel. Countermeasures were designed to address these main root causes and were implemented through iterative plan-do-study-act (PDSA) cycles. Interventions included provider education and features within the electronic health record, which were introduced sequentially, culminating in the creation of a best practice advisory (BPA). We performed biweekly chart reviews of visits for applicable patients to establish baseline performance rate and track progress over time. We used a statistical process control p-chart to analyze the outcome measure of documented counseling. As a balancing measure, clinicians were surveyed using the Technology Adoption Model survey to assess acceptance of the BPA. RESULTS From September 2019 to August 2022, the QI team improved rates of documented folic acid counseling from 23% to 73% through several PDSA cycles. This level of performance has been sustained over time. The most successful and sustainable intervention was the BPA. Provider acceptance of the BPA was overall positive. SIGNIFICANCE We successfully used QI methodology to improve and sustain our rates of documented folic acid supplementation counseling for adolescent females with epilepsy.
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Affiliation(s)
- Sara E Molisani
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Darshana Parikh
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marissa DiGiovine
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dennis Dlugos
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mark P Fitzgerald
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Epilepsy Neurogenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy and Neurodevelopmental Disorders Center, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lawrence Fried
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ingo Helbig
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Epilepsy Neurogenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy and Neurodevelopmental Disorders Center, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sudha Kilaru Kessler
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Pamela Pojomovsky McDonnell
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Epilepsy Neurogenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan Melamed
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marisa S Prelack
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Uzma Sharif
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sarah Tefft
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy Neurogenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy and Neurodevelopmental Disorders Center, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jaclyn Tencer
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stephanie Witzman
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kathy Shaw
- Department of Pediatrics (Division of Emergency Medicine), Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nicholas S Abend
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Hosny H, Al Kattan MM, Zaki MA, Ramzy GM, Al-Azayem SA, Magdy R. Seizure control during pregnancy and postpartum period in women with epilepsy: an Egyptian prospective study. BMC Neurol 2023; 23:54. [PMID: 36732706 PMCID: PMC9893555 DOI: 10.1186/s12883-023-03086-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 01/23/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Proper seizure control during pregnancy and postpartum is essential to optimize the outcome of women with epilepsy (WWE). The current work aimed to address factors related to seizure occurrence during pregnancy and postpartum. METHODS One hundred twenty-five WWE, compliant with their anti-seizure medications (ASMs) regimen, were prospectively evaluated for seizure control and ASMs changes all through the pregnancy up to 4 weeks postpartum. RESULTS Most of the patients, 73 (58.4%), completed their pregnancy without seizures, while 52 (41.6%) had seizures. Only one case developed one episode of convulsive status epilepticus in the third trimester. Due to breakthrough seizures, the ASM dose was increased from the first to the third trimester in 19.2% of pregnancies, while another ASM was added in 8 pregnancies. Uncontrolled seizures during the six months before pregnancy were associated with a four-fold increase in the risk of seizures during pregnancy (95% CI 2.476-6.695). The latter nearly doubled the risk of seizures during the postpartum period (RR 1.978) (95% CI 1.44 -2.717). Furthermore, genetic etiology would increase the risk of seizures during the postpartum period by 2.7 times more than the unknown etiology (RR 2.778, 95%CI 1.156-6.679). CONCLUSION Women with epilepsy should be counselled that proper seizure control six months before pregnancy is necessary to pass their pregnancy and the postpartum period without seizures.
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Affiliation(s)
- Hassan Hosny
- grid.7776.10000 0004 0639 9286Department of Neurology, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Manal Mahmoud Al Kattan
- grid.7776.10000 0004 0639 9286Department of Neurology, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maha A. Zaki
- grid.7776.10000 0004 0639 9286Department of Neurology, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Gihan M. Ramzy
- grid.7776.10000 0004 0639 9286Department of Neurology, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Salsabil Abo Al-Azayem
- grid.7776.10000 0004 0639 9286Department of Neurology, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rehab Magdy
- grid.7776.10000 0004 0639 9286Department of Neurology, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
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McNulty ML. Gender Issues in Epileptic Patients. Neurol Clin 2023; 41:249-263. [PMID: 37030956 DOI: 10.1016/j.ncl.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Treatment approaches for epilepsy for both women and men are similar, however, there are special aspects that must be considered when caring for women with epilepsy. This includes how hormonal fluctuations may affect seizure frequency, contraception, and potential drug-drug interactions, and pregnancy planning to minimize and potentially mitigate any adverse neurodevelopmental outcomes and major congenital malformations. Adequate counseling for women across the lifespan can help prepare women for the future and optimize outcomes.
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Affiliation(s)
- Maggie L McNulty
- Department of Neurology, Rush University Medical Center, 1725 West Harrison Street Suite 885, Chicago, IL 60612, USA.
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Di Filippo S, Godoy DA, Manca M, Paolessi C, Bilotta F, Meseguer A, Severgnini P, Pelosi P, Badenes R, Robba C. Ten Rules for the Management of Moderate and Severe Traumatic Brain Injury During Pregnancy: An Expert Viewpoint. Front Neurol 2022; 13:911460. [PMID: 35756939 PMCID: PMC9218270 DOI: 10.3389/fneur.2022.911460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022] Open
Abstract
Moderate and severe traumatic brain injury (TBI) are major causes of disability and death. In addition, when TBI occurs during pregnancy, it can lead to miscarriage, premature birth, and maternal/fetal death, engendering clinical and ethical issues. Several recommendations have been proposed for the management of TBI patients; however, none of these have been specifically applied to pregnant women, which often have been excluded from major trials. Therefore, at present, evidence on TBI management in pregnant women is limited and mostly based on clinical experience. The aim of this manuscript is to provide the clinicians with practical suggestions, based on 10 rules, for the management of moderate to severe TBI during pregnancy. In particular, we firstly describe the pathophysiological changes occurring during pregnancy; then we explore the main strategies for the diagnosis of TBI taking in consideration the risks related to mother and fetus, and finally we discuss the most appropriate approaches for the management in this particular condition. Based on the available evidence, we suggest a stepwise approach consisting of different tiers of treatment and we describe the specific risks according to the severity of the neurological and systemic conditions of both fetus and mother in relation to each trimester of pregnancy. The innovative feature of this approach is the fact that it focuses on the vulnerability and specificity of this population, without forgetting the current knowledge on adult non-pregnant patients, which has to be applied to improve the quality of the care process.
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Affiliation(s)
- Simone Di Filippo
- Department of Biotechnology and Sciences of Life, Anesthesia and Intensive Care, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina
- Intensive Care, Hospital Carlos Malbran, Catamarca, Argentina
| | - Marina Manca
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - Camilla Paolessi
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - Federico Bilotta
- Department of Anesthesiology, University of Rome “Sapienza”, Rome, Italy
| | - Ainhoa Meseguer
- Department of Obstetrics, Hospital Francesc de Borja, Gandia, Spain
| | - Paolo Severgnini
- Department of Biotechnology and Sciences of Life, Anesthesia and Intensive Care, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de València, Universitat de València, Valencia, Spain
| | - Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genova, Italy
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Coker JL, Ray-Griffith SL, McLeod C, Han X, Mancino M, Kearns GL, Stowe ZN. Clearance of buprenorphine during pregnancy and neonatal outcomes. Arch Womens Ment Health 2021; 24:933-939. [PMID: 33864131 DOI: 10.1007/s00737-021-01128-1] [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: 08/04/2020] [Accepted: 04/03/2021] [Indexed: 11/28/2022]
Abstract
Buprenorphine is emerging as the preferred pharmacologic treatment for opioid use disorder during pregnancy. We examined the relative plasma clearance of buprenorphine (BUP) across pregnancy. Pregnant women with opioid use disorder participating in a prospective, observational study from 2013 to 2016 on stress in pregnancy who were receiving BUP for opioid use disorder were included. Women with an active eating disorder or suicidal ideation were excluded. Research visits occurred at 4-6-week intervals across pregnancy and the early postpartum period and included medication exposure history and blood samples. All assays for BUP serum concentrations at steady state were completed. Relative weight-adjusted clearance (Cl) was calculated using Cl = (daily dose [mg]/ body weight [kg])/serum concentration [ng/ml]. We collected 112 maternal blood samples from 29 women throughout pregnancy and the postpartum period. Serum concentrations for BUP ranged from < 0.2 to 15.8 ng/ml. Eleven women, with greater than three collected samples, increased their daily dose of BUP during pregnancy; however, there were no significant differences in relative clearance of BUP across this same period. This data suggests that women with opioid use disorder receiving BUP did not demonstrate a significant increase in BUP clearance across pregnancy despite increase in dosages during pregnancy. When selecting an appropriate BUP dosage for management of perinatal opioid use disorder, gestational stage appears not to be an important covariate and should be based on an individualized approach.
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Affiliation(s)
- Jessica L Coker
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA.
| | - Shona L Ray-Griffith
- Department of Psychiatry and Obstetrics & Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Cody McLeod
- Department of Orthopedics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Xiaotong Han
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA
| | - Michael Mancino
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA
| | - Gregory L Kearns
- Departments of Medical Education and Pediatrics, Texas Christian University, UNTHSC School of Medicine, Fort Worth, TX, USA
| | - Zachary N Stowe
- Department of Psychiatry, University of Wisconsin, Madison, WI, USA
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Algahtani H, Shirah B, Alkahtani F, Alrefaei K, Alamri A, Aldarmahi A. Antiepileptic Drugs Usage in Pregnant Women with Epilepsy in Saudi Arabia. J Epilepsy Res 2020; 9:134-138. [PMID: 32509549 PMCID: PMC7251344 DOI: 10.14581/jer.19014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 01/05/2020] [Accepted: 01/06/2020] [Indexed: 11/03/2022] Open
Abstract
Background and Purpose Epilepsy is one of the most common neurological disorders requiring continuous treatment during pregnancy. In Saudi Arabia, there is only one publication that studied the outcome of pregnancies in women with epilepsy, published in 1999. The aim of the study is to determine the major congenital malformations in infants resulting from exposure to antiepileptic drugs in pregnant women with epilepsy. Methods This is a retrospective observational study that was conducted at King Abdulaziz Medical City, Jeddah, Saudi Arabia, involving pregnant women with epilepsy using antiepileptic drugs during pregnancy. We also studied babies born to those mothers. The study period was 5 years from 2014 to 2018. Results Six hundred babies were included in the study, born to 154 mothers with epilepsy using antiepileptic drugs during pregnancy. In addition, there were 111 losses of fetuses before 20 weeks of gestation. The only malformation detected was a ventricular septal defect in one child, whose mother was using polytherapy (valproic acid and levetiracetam). Three babies were born with epilepsy, and four babies had other associated disorders (Down syndrome, osteoporosis, esotropia, and hearing impairment). Conclusions The results of this small study are an urgent call for the establishment of congenital malformations registry in Saudi Arabia. In addition, specialized epilepsy clinics utilizing multidisciplinary care are highly recommended. A specific group of interest for such clinics are married women, who have epilepsy and are using antiepileptic drugs since planning of pregnancy is not part of the culture in Saudi Arabia.
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Affiliation(s)
- Hussein Algahtani
- King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Bader Shirah
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Faisal Alkahtani
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Khalid Alrefaei
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Abdulrahman Alamri
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ahmed Aldarmahi
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
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Dupont S. Trattamento medico dell’epilessia dell’adulto. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)43686-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Melikova S, Bagirova H, Magalov S. The impact of maternal epilepsy on delivery and neonatal outcomes. Childs Nerv Syst 2020; 36:775-782. [PMID: 31786631 DOI: 10.1007/s00381-019-04435-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/06/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE Epilepsy is a common neurological disorder that may complicate reproductive health. Our aim in this study was to provide prospective ascertainment of obstetric and neonatal outcomes in women with epilepsy and investigate whether the risk of pregnancy, delivery, and neonatal complications differed between women with epilepsy and women without epilepsy. METHODS Pregnant women with epilepsy and women without epilepsy (control group) were prospectively evaluated during the years 2013-2018. They were regularly followed by a neurologist and obstetrician until the end of pregnancy. RESULTS Delivery and perinatal outcomes were compared between 112 women diagnosed with epilepsy and 277 women without epilepsy. Epilepsy was a significant risk factor for preterm delivery, cesarean section, fetal hypoxia, and Apgar score ≤ 7 at 5 min in offspring (odds ratio (OR) = 2.83, 95% confidence interval (CI) 1.03-7.76; OR = 5.61, 95% CI 3.44-9.14; OR = 1.81, 95% CI 1.08-3.04; OR = 8.12, 95% CI 4.04-16.35, respectively). Seizures during pregnancy had influence on the preference of cesarean section as a mode of delivery (ОR = 3.39; 95% CI 1.40-8.17). The rate of perinatal hypoxia was significantly higher in children born by cesarean section (ОR = 2.84; 95% CI 1.04-7.76). There was no significant difference between women with epilepsy and controls in malformation rate. CONCLUSIONS Women with epilepsy had an increased risk of pregnancy and delivery complications. Cesarean section was associated with an increased risk of complications in offspring.
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Affiliation(s)
- Shahla Melikova
- Department of Neurology, Azerbaijan Medical University, Mardanov Qardashlari, 100, AZ 1078, Baku, Azerbaijan.
| | - Hijran Bagirova
- Department of Obstetrics and Gynecology II, Azerbaijan Medical University, Mirgasimov, 1004, Baku, Azerbaijan
| | - Sharif Magalov
- Department of Neurology, Azerbaijan Medical University, Mardanov Qardashlari, 100, AZ 1078, Baku, Azerbaijan
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Elkady EF, Aboelwafa AA, Fouad MA. Study of gender-related pharmacokinetics of ezogabine in Egyptian volunteers by a validated LC-MS/MS bioanalytical method. J Adv Res 2020; 22:99-104. [PMID: 31956446 PMCID: PMC6961218 DOI: 10.1016/j.jare.2019.11.008] [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: 10/22/2019] [Revised: 11/17/2019] [Accepted: 11/18/2019] [Indexed: 11/25/2022] Open
Abstract
Gender-based pharmacokinetics and/or pharmacodynamics differences can result in differences in treatment which can accordingly affect the drug safety and/or efficacy. A new validated bio-analytical LC-MS/MS method was developed for the estimation of ezogabine, a third-generation antiepileptic drug, in human plasma using oxcarbazepine as an internal standard (IS) and to study the gender effect on the pharmacokinetic parameters in Egyptian human subjects. Liquid-liquid extraction of plasma samples was performed with diethyl ether: dichloromethane. The separation was accomplished in an isocratic mode with a mobile phase of a mixture of 5 mM ammonium acetate: methanol: acetonitrile pumped on a reversed phase C18 INERTSIL ODS-3 (5 µm, 150 × 4.6 mm). Multiple reaction monitoring was applied and operated by positive mode electrospray ionization. Male and female Cmax (p = 0.0308; CL = 95) and t1/2 (p = 0.0301; CL = 95) were found to be significantly different using Mann-Whitney U test. These findings highlight the difference of ezogabine pharmacokinetics among populations. Further, gender-based ezogabine dose adjustment may be considered.
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Affiliation(s)
- Ehab F Elkady
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr El-Aini 11562, Cairo, Egypt
| | - Ahmed A Aboelwafa
- Pharmaceutics and Industrial Pharmacy Department, Faculty of Pharmacy, Cairo University, Kasr El-Aini 11562, Cairo, Egypt
| | - Marwa A Fouad
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr El-Aini 11562, Cairo, Egypt
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10
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Antiseizure drugs use during pregnancy and congenital malformations: A retrospective review from the United Arab Emirates. Epilepsy Res 2020; 159:106259. [PMID: 31901526 DOI: 10.1016/j.eplepsyres.2019.106259] [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: 10/01/2019] [Revised: 11/21/2019] [Accepted: 12/20/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To observe the incidence of congenital malformations occurring in foetuses exposed to antiseizure drugs (ASDs) during the first trimester and to identify individual drug associations in a population cohort from the United Arab Emirates (UAE). METHODS Pregnancy outcomes were observed and reported from women with epilepsy (WWE), attending the Obstetric Medicine Neurology Clinic at Corniche Hospital in Abu Dhabi, United Arab Emirates (UAE) from February 2008 to December 2015. RESULTS Outcome data were available for 179 pregnancies in 112 WWE. There were 139 pregnancies who received ASD treatment during the first trimester, of these 124 were on monotherapy. Thirteen (7.26 %) congenital malformations (CMs) were observed in this cohort, seven were major ones and six were minor. Thirteen of the CMs were from the group with ASDs while one had no ASD-exposure. From the ASD-group, we identified 32 (23.0 %) with poor pregnancy outcomes, including 13 (9.3 %) with CMs and 19 (13.7 %) miscarriages. These figures were significantly higher than that of the no ASD-exposure group (7.9 %) (p = 0.04, Fisher test). The most commonly used ASDs in monotherapy were levetiracetam (25.6 %), carbamazepine (16.2 %), valproate (13.4 %), and lamotrigine (7.3 %). There were 57 (31.8 %) consanguineous marriages in this cohort; there was no statistically significant difference in the CM rate within the consanguineous group between those with and without exposure to ASD. CONCLUSION This study was the first to report pregnancy outcomes in a WWE cohort from the Middle East and North Africa (MENA) region. It is the first step towards establishing a national / regional pregnancy registry to create a database on ASD use and pregnancy outcomes among the WWE.
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Barnard S, French J. Collaboration of Care for Women with Epilepsy in their Reproductive Years. J Womens Health (Larchmt) 2019; 28:339-345. [PMID: 30767686 DOI: 10.1089/jwh.2018.7506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Over half a million women of childbearing age have epilepsy, many of which will require family planning care at some point in their reproductive years. Matters relating to contraception, pregnancy, fertility, and sexual functioning are all impacted to varying degrees by the use of antiepileptic drugs (AEDs) to treat epilepsy and require active management by a woman's neurologist. It is important that a woman's obstetrician/gynecologist (OBGYN) and internist are aware of the way in which their care may be related to her epilepsy care and how this can be successfully comanaged with her neurologist. This includes the impact AED therapies have on pregnancy, such as risk of teratogenicity, changes to AED clearance rates during pregnancy and postpartum, and risk of seizure worsening while pregnant; interactions of hormonal contraceptives and AEDs; side effects of AED treatment on hormonal systems and sexual functioning; and matters of fertility and infertility treatments. The current editorial discusses these relationships between AED choice, dose, and family planning matters for women with epilepsy in their childbearing years to support the collaboration of care between her neurologist, OBGYN, and internist.
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Siewe Fodjo JN, Dekker MCJ, Idro R, Mandro MN, Preux PM, Njamnshi AK, Colebunders R. Comprehensive management of epilepsy in onchocerciasis-endemic areas: lessons learnt from community-based surveys. Infect Dis Poverty 2019; 8:11. [PMID: 30738437 PMCID: PMC6368958 DOI: 10.1186/s40249-019-0523-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 01/23/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Onchocerciasis-endemic regions are known to have a high epilepsy prevalence. Limited resources in these areas and poor access to healthcare by persons with epilepsy (PWE) result in a wide anti-epileptic treatment gap, poor seizure control and a high burden of seizure-related complications. Recent community-based surveys highlight the need for epilepsy management strategies suitable for remote onchocerciasis-endemic villages to ensure better health outcomes for PWE. In this paper, we propose a feasible approach to manage PWE in such settings. MAIN TEXT Improved management of PWE in onchocerciasis-endemic areas may be achieved by decentralizing epilepsy care. Simplified approaches for the diagnosis and treatment of epilepsy may be used by non-physicians, under the supervision of physicians or specialists. To reduce the treatment gap, a regular supply of subsidized anti-epileptic drugs (AED) appropriate for different types of onchocerciasis-associated epilepsy should be instituted. Setting up a community-based epilepsy surveillance system will enable early diagnosis and treatment of PWE thereby preventing complications. Community awareness programs on epilepsy must be implemented to reduce stigma and facilitate the social rehabilitation of PWE. Finally, strengthening onchocerciasis elimination programs by optimizing community-directed treatment with ivermectin (CDTI) and considering alternative treatment strategies might reduce the incidence of epilepsy. CONCLUSIONS A community-based approach with task-shifting of epilepsy care from specialists to non-physician health workers will reduce epilepsy-associated morbidity. Increased advocacy and collaboration with various stakeholders is needed to establish a sustainable, cost-effective chronic care model for epilepsy that will significantly improve the quality of life of PWE in onchocerciasis-endemic regions.
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Affiliation(s)
| | - Marieke C. J. Dekker
- Department of Internal Medicine and Pediatrics, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Neurology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Michel Ndahura Mandro
- Global Health Institute, University of Antwerp, Antwerp, Belgium
- Provincial Health Division Ituri, Ministry of Health, Bunia, Democratic Republic of the Congo
| | - Pierre-Marie Preux
- INSERM, Univ. Limoges, Tropical Neuroepidemiology, Institute of Neuroepidemiology and Tropical Neurology, GEIST, 87000, Limoges, CHU, UMR 1094 Limoges, France
| | - Alfred K. Njamnshi
- Department of Neurology, Yaoundé Central Hospital / FMBS, The University of Yaoundé 1, Yaoundé, Cameroon
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
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Oksuzoglu A, Engin Ustun Y, Aktulay A, Yoruk O, Seckin B, Danisman N. First and Second Trimester Biochemical Markers in Maternal Epilepsy: A Case-Control Study. Fetal Pediatr Pathol 2018; 37:319-325. [PMID: 30247941 DOI: 10.1080/15513815.2018.1502381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Our aim is to investigate whether the maternal serum levels of first and second trimester serum analytes are altered in women with epilepsy in pregnancy. METHODS Maternal serum biochemical markers (estriol, alpha-fetoprotein [AFP], human chorionic gonadotrophin [hCG], free β hCG, pregnancy-associated plasma protein-A) were compared in a series of 122 pregnant women with epilepsy and in a cohort of 122 normal pregnant women. The serum samples were obtained between 11-13 6/7 weeks and 16-18 weeks gestation. RESULTS Second trimester serum estriol levels, expressed as multiples of the median (MoM), in the epileptic group (1.55 ± 0.77 MoM) were significantly higher than those in the control patients (1.13 ± 0.40 MoM) (p < 0.001). Of the women with epilepsy, 66.3% (n = 81) were exposed to antiepileptic drugs. CONCLUSION Our study revealed that otherwise uncomplicated pregnant epileptic women had higher second trimester (18-20 weeks of gestation) estriol levels compared to non-epileptic pregnant women.
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Affiliation(s)
- Aysegul Oksuzoglu
- a Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Research and Education Hospital , Ankara , Turkey
| | - Yaprak Engin Ustun
- a Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Research and Education Hospital , Ankara , Turkey
| | - Ayla Aktulay
- a Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Research and Education Hospital , Ankara , Turkey
| | - Ozlem Yoruk
- a Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Research and Education Hospital , Ankara , Turkey
| | - Berna Seckin
- a Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Research and Education Hospital , Ankara , Turkey
| | - Nuri Danisman
- a Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Research and Education Hospital , Ankara , Turkey
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Abstract
Concern about what is best practice when caring for women with neurologic disease is a common clinical scenario. Therefore, knowledge about women's health issues and their intersection with neurologic disorders is imperative. This review will discuss the appropriate gender-based considerations in epilepsy, multiple sclerosis, migraine, autoimmune disease, sleep disorders, stroke, and paraneoplastic disorders.
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Galappatthy P, Liyanage CK, Lucas MN, Jayasekara DTLM, Abhayaratna SA, Weeraratne C, De Abrew K, Gunaratne PS, Gamage R, Wijeyaratne CN. Obstetric outcomes and effects on babies born to women treated for epilepsy during pregnancy in a resource limited setting: a comparative cohort study. BMC Pregnancy Childbirth 2018; 18:230. [PMID: 29898689 PMCID: PMC6000926 DOI: 10.1186/s12884-018-1857-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 05/25/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Management of epilepsy during pregnancy in a resource-limited setting (RLS) is challenging. This study aimed to assess obstetric outcomes and effects on babies of women with epilepsy (WWE) exposed to Anti-epileptic drugs (AEDs) compared to non-exposed controls in a RLS. METHODS Pregnant WWE were recruited from antenatal and neurology clinics of a tertiary care hospitals in Sri Lanka. Patients were reviewed in each trimester and post-partum. Medication adherence, adverse effects, seizure control and carbamazepine blood levels were monitored. Post-partum, measurements for anthropometric and dysmorphic features of the babies and congenital abnormalities were recorded. Age and sex matched babies not exposed to AED recruited as controls were also examined. RESULTS Ninety-six pregnant WWE were recruited (mean period of gestation 22.9 weeks). Mean age was 28 years and 48(50%) were primigravidae. Fifty percent (48) were on monotherapy, while 23.8, 15.9 and 4.1% were on two, three and four AEDs respectively. AEDs in first trimester (TM1) were carbamazepine (71%), valproate (25.8%) clobazam (29.5%), lamotrigine (7%) topiramate (5%) and others (3.4%). Sodium valproate use reduced significantly from T1 to T2(p < 0.05). Sub-therapeutic carbamazepine levels correlated positively (r = 0.547) with poor medication adherence (p = 0.009) and negatively (r = 0.306) with adverse effects (p = 0.002). Seventy-six WWE completed follow-up reporting w 75 (98.6%) live births and one T1 miscarriage (1.3%). Three (4.3%) were preterm. Majority (73.33%) were normal vaginal deliveries. Cesarean sections were not increased in WWE. Fifty-nine (61.45%) babies were examined. For those examined during infancy, 53 age and sex matched controls were recruited and examined.. Congenital abnormalities occurred in 5 (9.43%) babies of WWE [atrio-ventricular septal defect (2), renal hypoplasia (1), cryptorchidism (1), microcephaly (1)] compared to 2 (3.77%) in controls (2 microcephaly; p = 0.24). Fetal exposure to AEDs increased a risk of low birth weight (RR 2.8; p = 0.049). Anthropometric parameters of AED exposed babies were lower at birth but not statistically significant between the two groups (weight p = 0.263, length p = 0.363, occipito-frontal circumference (OFC) p = 0.307). However, weight (p = 0.009), length (p = 0.016) and OFC (p = 0.002) were significantly lower compared to controls at an average of 3.52 months. CONCLUSION Most pregnancies are unplanned in the RLS studied, and AEDs were altered during pregnancy. Congenital anomalies occurred at rates comparable to previous reports. Fetal exposure to AED had growth retardation in infancy compared to non-exposed babies.
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Affiliation(s)
| | | | - Marianne Nishani Lucas
- Department of Peadiatrics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | | | - Chamari Weeraratne
- Department of Pharmacology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Kusum De Abrew
- Department of Pharmacology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | | | - Chandrika N. Wijeyaratne
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Rezaallah B, Lewis DJ, Zeilhofer HF, Berg BI. Risk of Cleft Lip and/or Palate Associated With Antiepileptic Drugs: Postmarketing Safety Signal Detection and Evaluation of Information Presented to Prescribers and Patients. Ther Innov Regul Sci 2018; 53:110-119. [PMID: 29714593 DOI: 10.1177/2168479018761638] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The aim was to analyze safety data associated with the maternal use of antiepileptic drugs in pregnancy and to assess the risk of cleft lip and/or palate (CL/P) as an outcome in the neonate. A parallel objective was to assess the completeness of the safety information concerning pregnancy exposures in the Summary of Product Characteristics (SmPCs) and the Patient Information (PI) in the USA and the UK. METHODS We analyzed individual case safety reports of CL/P associated with antiepileptic drugs in the FDA Adverse Event Reporting System. For the antiepileptic drugs with signals (EB05 ≥ 2), we reviewed Drug Analysis Prints for CL/P cases in the UK Medicines and Healthcare products Regulatory Agency (MHRA). We performed descriptive analyses of relevant SmPCs and PIs in the UK and the USA using a checklist of recommendations collected from the literature. RESULTS In total 817 CL/P reports were identified for 12 antiepileptic drugs in the FDA Adverse Event Reporting System. Ten of the 12 antiepileptic drugs were associated with 156 CL/P cases in the MHRA Sentinel. Safety information concerning pregnancy was found to be more comprehensive in UK SmPCs than in the US equivalents. CONCLUSIONS There is statistical disproportionality in individual case safety reports indicative of an increased risk of CL/P with 12 antiepileptic drugs studied. More studies are required to explore the association between in utero exposure to antiepileptic drugs and the risk of CL/P. There are inconsistencies between the UK and US safety labels. CL/P associated with antiepileptic drugs is an important topic and requires providing inclusive, unbiased, up-to-date information to prescribers and women of childbearing age.
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Affiliation(s)
- Bita Rezaallah
- 1 Department of Clinical Research, University of Basel, Basel, Switzerland.,2 Patient Safety, Novartis Global Drug Development, Novartis Pharma Basel, Switzerland
| | - David John Lewis
- 2 Patient Safety, Novartis Global Drug Development, Novartis Pharma Basel, Switzerland.,3 School of Health and Human Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Hans-Florian Zeilhofer
- 4 Department of Cranio-Maxillofacial Surgery, University Hospital Basel, Basel, Switzerland.,5 Hightech Research Center of Cranio-Maxillofacial Surgery, University of Basel, Basel, Switzerland
| | - Britt-Isabelle Berg
- 4 Department of Cranio-Maxillofacial Surgery, University Hospital Basel, Basel, Switzerland.,5 Hightech Research Center of Cranio-Maxillofacial Surgery, University of Basel, Basel, Switzerland.,6 Division of Oral and Maxillofacial Radiology, Columbia University Medical Center, New York City, NY, USA
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Ishiguro Y, Furugen A, Narumi K, Nishimura A, Hirano T, Kobayashi M, Iseki K. Valproic acid transport in the choriocarcinoma placenta cell line JEG-3 proceeds independently of the proton-dependent transporters MCT1 and MCT4. Drug Metab Pharmacokinet 2018; 33:270-274. [PMID: 30341000 DOI: 10.1016/j.dmpk.2018.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/21/2018] [Accepted: 03/19/2018] [Indexed: 01/06/2023]
Abstract
Medication therapy is the first line of treatment in the management of epilepsy. Fetal exposure to valproic acid (VPA), an antiepileptic drug, poses an elevated risk of teratogenicity in early pregnancy. Some studies have reported that monocarboxylate transporters (MCTs) may be involved in the placental transport of VPA. However, it has not been determined which MCTs contribute to VPA transport into the placenta. Therefore, the aim of this study was to determine how MCTs contribute to VPA transport into the placenta using the human placenta choriocarcinoma cell line JEG-3. VPA uptake was investigated using JEG-3 cells and radiolabeled VPA. MCT expression in JEG-3 cells was detected using RT-PCR and western blotting. Knockdown of MCTs was carried out using siRNAs. VPA uptake into JEG-3 cells was pH- and concentration-dependent, and described by using the Michaelis-Menten equation (Km = 0.95 ± 0.17 mM; Vmax = 19.3 ± 1.21 nmol/mg protein/15 s). MCT1 and MCT4 expression was found in JEG-3 cells, and typical MCT inhibitors significantly inhibited VPA uptake into JEG-3 cells. However, knockdown of MCT1 and MCT4 did not alter VPA uptake. In conclusion, VPA transport is mediated by a proton-dependent transporter in JEG-3 cells, but not by MCT1 and MCT4.
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Affiliation(s)
- Yuri Ishiguro
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-jo, Nishi-6-chome, Kita-ku, Sapporo 060-0812, Japan
| | - Ayako Furugen
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-jo, Nishi-6-chome, Kita-ku, Sapporo 060-0812, Japan
| | - Katsuya Narumi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-jo, Nishi-6-chome, Kita-ku, Sapporo 060-0812, Japan
| | - Ayako Nishimura
- Department of Pharmacy, Hokkaido University Hospital, Sapporo 060-8648, Japan
| | - Takeshi Hirano
- Health Sciences University of Hokkaido, 1757 Kanazawa, Tobetsu-cho, Ishikari-gun, Hokkaido 061-0293, Japan
| | - Masaki Kobayashi
- Department of Pharmacy, Hokkaido University Hospital, Sapporo 060-8648, Japan.
| | - Ken Iseki
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-jo, Nishi-6-chome, Kita-ku, Sapporo 060-0812, Japan; Department of Pharmacy, Hokkaido University Hospital, Sapporo 060-8648, Japan.
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Abstract
BACKGROUND This study aims to improve the rate of folic acid supplementation to adolescent women with epilepsy on an antiepileptic drug (AED) regimen seen by the pediatric neurology providers at the Children's Hospital at Montefiore, in compliance with the 2009 American Academy of Neurology and American Epilepsy Society practice parameter. METHODS We designed a quality improvement study with implementation of a series of interventions and compared folic acid supplementation rates before and after intervention. We made additional comparisons based on specific age groups (12 to 15 years and 16 to 21 years) and a diagnosis with or without developmental impairment. RESULTS A review of 1850 charts from 2004 to 2015 showed an average folic acid prescription rate of 41%. Supplementation rates gradually increased to 52.2%, 58.5%, 60.3%, and finally up to 81.6% after this respective intervention: initial email reminder, provider education, posting signs in examination rooms, and implementation of an electronic medical record best practice advisory. There was improvement across all categories, in both age groups (12 to 15 years and 16 to 21 years) and in those with or without developmental impairment. There was a trend for higher compliance rates in adolescents without developmental impairment. CONCLUSIONS Our interventions resulted in an increase in folic acid supplementation rates of adolescent women with epilepsy. These results are encouraging. We plan to extend education about the recommendations for folic acid supplementation to non-neurology providers, as well as expand to apply our interventions and assess adherence to other defined epilepsy quality measures.
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Affiliation(s)
- Puja Patel
- Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York; Department of Pediatrics, Children's Hospital at Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
| | - Jules C Beal
- Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York; Department of Pediatrics, Children's Hospital at Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Shlomo Shinnar
- Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York; Department of Pediatrics, Children's Hospital at Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
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Shawahna R. Which information on women's issues in epilepsy does a community pharmacist need to know? A Delphi consensus study. Epilepsy Behav 2017; 77:79-89. [PMID: 29127865 DOI: 10.1016/j.yebeh.2017.09.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/08/2017] [Accepted: 09/22/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of this study was to develop and achieve consensus on a core list of important knowledge items that community pharmacists should know on women's issues in epilepsy. METHODS This was a consensual study using a modified Delphi technique. Knowledge items were collected from the literature and from nine key contacts who were interviewed on their views on what information community pharmacists should have on women's issues in epilepsy. More knowledge items were suggested by five researchers with interest in women's issues who were contacted to rate and comment on the knowledge items collected. Two iterative Delphi rounds were conducted among a panel of pharmacists (n=30) to achieve consensus on the knowledge items to be included in the core list. Ten panelists ranked the knowledge items by their importance using the Analytical Hierarchy Process (AHP). RESULTS Consensus was achieved to include 68 knowledge under 13 categories in the final core list. Items ranked by their importance were related to the following: teratogenicity (10.3%), effect of pregnancy on epilepsy (7.4%), preconception counseling (10.3%), bone health (5.9%), catamenial epilepsy (7.4%), menopause and hormonal replacement therapy (2.9%), contraception (14.7%), menstrual disorders and infertility (8.8%), eclampsia (2.9%), breastfeeding (4.4%), folic acid and vitamin K (5.9%), counseling on general issues (14.7%), and sexuality (4.4%). CONCLUSION Using consensual knowledge lists might promote congruence in educating and/or training community pharmacists on women's issues in epilepsy. Future studies are needed to investigate if such lists can improve health services provided to women with epilepsy (WWE).
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Affiliation(s)
- Ramzi Shawahna
- Department of Physiology, Pharmacology and Toxicology, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine; An-Najah BioSciences Unit, Centre for Poisons Control, Chemical and Biological Analyses, An-Najah National University, Nablus, Palestine.
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Al-Rubai AJ, Wigmore P, Pratten MK. Evaluation of a human neural stem cell culture method for prediction of the neurotoxicity of anti-epileptics. Altern Lab Anim 2017; 45:67-81. [PMID: 28598192 DOI: 10.1177/026119291704500202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Human neural stem cells have been proposed as an in vitro model to predict neurotoxicity. In this study, the potential of in vitro cultures of human-derived neurospheres to predict the effects of various anti-epileptic drugs (sodium valproate, phenytoin, carbamazepine and phenobarbitone) was evaluated. In general, these drugs had no significant effects on cell viability, total cellular protein, and neuronal process length at low doses, but at high doses these parameters were reduced significantly. Therapeutic doses of sodium valproate and phenytoin had a clear effect on neurosphere size and cell migration, with a significant reduction in both parameters when compared with the control group. The other drugs (carbamazepine and phenobarbitone) reduced neurosphere size and cell migration only at higher doses. The expression levels of glial fibrillary protein and tubulin III, which were used to identify astrocytes and neuronal cells, respectively, were reduced in a dose-dependent manner that became significant at high doses. The levels of glial fibrillary protein did not indicate any occurrence of reactive astrocytosis.
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Affiliation(s)
- Abdal-Jabbar Al-Rubai
- College of Medicine, Almustansiriyah University, Baghdad, Iraq and School of Life Sciences, The University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Peter Wigmore
- School of Life Sciences, The University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Margaret K Pratten
- School of Life Sciences, The University of Nottingham, Queen's Medical Centre, Nottingham, UK
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Herzog AG, Mandle HB, Cahill KE, Fowler KM, Hauser WA. Predictors of unintended pregnancy in women with epilepsy. Neurology 2017; 88:728-733. [DOI: 10.1212/wnl.0000000000003637] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 11/16/2016] [Indexed: 11/15/2022] Open
Abstract
Objective:To determine whether rates of unintended pregnancy in women with epilepsy (WWE) vary by contraceptive category and when stratified by antiepileptic drug (AED) category.Methods:These retrospective data come from the Epilepsy Birth Control Registry (EBCR) web-based survey of 1,144 WWE in the community, 18–47 years of age, who provided demographic, epilepsy, AED, contraceptive, and pregnancy data. Participants indicated whether pregnancies were intended or unintended, as well as the type of contraceptive and AED used at conception. We report failure rates relative to the frequency of use of each contraceptive category in the EBCR.Results:Most WWE (78.9%) reported having at least one unintended pregnancy; 65.0% of their pregnancies were unintended. Unintended pregnancy was more common among younger, racial minority, and Hispanic WWE. Among reversible contraceptive categories, the intrauterine device had the lowest failure rate. Failure rates varied greatly on systemic hormonal contraception (HC), depending on whether oral or nonoral forms were used and especially in relation to the category of AED with which HC was combined. Oral forms had greater failure rate than nonoral forms. HC combined with enzyme-inducing AEDs had a substantially greater failure rate than HC combined with no AED or any other AED category and in comparison to barrier plus any AED category. Other AED–HC combinations, in contrast, carried lower risks than barrier.Conclusions:Unintended pregnancy is common among WWE and may vary by contraceptive category and AED stratification. In view of the important consequences of unintended pregnancy on pregnancy outcomes, these retrospective findings warrant further prospective investigation.
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Abstract
BACKGROUND Women are commonly prescribed a variety of medications during pregnancy. As most organ systems are affected by the substantial anatomical and physiological changes that occur during pregnancy, it is expected that pharmacokinetics (PK) (absorption, distribution, metabolism, and excretion of drugs) would also be affected in ways that may necessitate changes in dosing schedules. The objective of this study was to systematically identify existing clinically relevant evidence on PK changes during pregnancy. METHODS AND FINDINGS Systematic searches were conducted in MEDLINE (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials (Ovid), and Web of Science (Thomson Reuters), from database inception to August 31, 2015. An update of the search from September 1, 2015, to May 20, 2016, was performed, and relevant data were added to the present review. No language or date restrictions were applied. All publications of clinical PK studies involving a group of pregnant women with a comparison to nonpregnant participants or nonpregnant population data were eligible to be included in this review. A total of 198 studies involving 121 different medications fulfilled the inclusion criteria. In these studies, commonly investigated drug classes included antiretrovirals (54 studies), antiepileptic drugs (27 studies), antibiotics (23 studies), antimalarial drugs (22 studies), and cardiovascular drugs (17 studies). Overall, pregnancy-associated changes in PK parameters were often observed as consistent findings among many studies, particularly enhanced drug elimination and decreased exposure to total drugs (bound and unbound to plasma proteins) at a given dose. However, associated alterations in clinical responses and outcomes, or lack thereof, remain largely unknown. CONCLUSION This systematic review of pregnancy-associated PK changes identifies a significant gap between the accumulating knowledge of PK changes in pregnant women and our understanding of their clinical impact for both mother and fetus. It is essential for clinicians to be aware of these unique pregnancy-related changes in PK, and to critically examine their clinical implications.
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Sharma A, Boller F, Koubeissi M. Women with epilepsy. FUNCTIONAL NEUROLOGY 2016; 31:125-6. [PMID: 27678204 DOI: 10.11138/fneur/2016.31.3.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kaur H, Kumar B, Medhi B. Antiepileptic drugs in development pipeline: A recent update. eNeurologicalSci 2016; 4:42-51. [PMID: 29430548 PMCID: PMC5803110 DOI: 10.1016/j.ensci.2016.06.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 04/16/2016] [Accepted: 06/15/2016] [Indexed: 12/18/2022] Open
Abstract
Epilepsy is the most common neurological disorder which significantly affects the quality of life and poses a health as well as economic burden on society. Epilepsy affects approximately 70 million people in the world. The present article reviews the scientific rationale, brief pathophysiology of epilepsy and newer antiepileptic drugs which are presently under clinical development. We have searched the investigational drugs using the key words ‘antiepileptic drugs,’ ‘epilepsy,’ ‘Phase I,’ ‘Phase II’ and ‘Phase III’ in American clinical trial registers (clinicaltrials.gov), the relevant published articles using National Library of Medicine's PubMed database, company websites and supplemented results with a manual search of cross-references and conference abstracts. This review provides a brief description about the antiepileptic drugs which are targeting different mechanisms and the clinical development status of these drugs. Besides the presence of old as well as new AEDs, still there is a need of new drugs or the modified version of old drugs in order to make affected people free of seizures. An optimistic approach should be used to translate the success of preclinical testing to clinical practice. There is an urgent need to improve animal models and to explore new targets with better understanding in order to develop the novel drugs with more efficacy and safety. This review primarily focused on antiepileptic drugs under clinical development. The more realistic approach is needed to discover and develop the novel antiepileptic drugs. Modification of conventional drugs or search of newer targets can lead to development of promising antiepileptic drugs. To develop more efficacious and safe drugs for treatment of epilepsy and refractory seizures There are a number of novel antiepileptic compounds which are under various stages of drug development.
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Affiliation(s)
- Harjeet Kaur
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Baldeep Kumar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Bikash Medhi
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Abstract
Epilepsy and antiepileptic drugs affect the menstrual cycle, aspects of contraception, reproductive health, pregnancy, and menopause through alteration of sex steroid hormone pathways. Sex steroid hormones often have an effect on seizure frequency and may alter the level of some antiepileptic drugs. Approximately one-third of women experience an increase in perimenstrual and/or periovulatory seizure frequency. Some women experience an increase in seizure frequency during pregnancy. Balancing maternal seizure control and the risk of congenital malformations associated with fetal antiepileptic drug exposure may be challenging. Some antiepileptic drugs are associated with cognitive and behavioral teratogenesis and should be avoided if possible during pregnancy.
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Affiliation(s)
- Naymeé J Vélez-Ruiz
- Division of Epilepsy, Department of Neurology, University of Miami, 1120 Northwest, 14th Street, Suite 1329, Miami, FL 33136, USA.
| | - Page B Pennell
- Division of Epilepsy, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Harvard University, 75 Francis Street, Boston, MA 02115, USA; Division of Women's Health, Brigham and Women's Hospital, Harvard Medical School, Harvard University, 75 Francis Street, Boston, MA 02115, USA
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Abstract
Many studies investigating cognitive outcomes in children of women with epilepsy report an increased risk of mental impairment. Verbal scores on neuropsychometric measures may be selectively more involved. While a variety of factors contribute to the cognitive problems of children of women with epilepsy, antiepileptic drugs (AEDs) appear to play a major role. The mechanisms by which AEDs affect neurodevelopmental outcomes remain poorly defined. Animal models suggest that AED-induced apoptosis, altered neurotransmitter environment, and impaired synaptogenesis are some of the mechanisms responsible for cognitive and behavioral teratogenesis. AEDs that are known to induce apoptosis, such as valproate, appear to affect children's neurodevelopment in a more severe fashion. Fetal valproate exposure has dose-dependent associations with reduced cognitive abilities across a range of domains, and these appear to persist at least until the age of 6. Some studies have shown neurodevelopmental deficiencies associated with the use of phenobarbital and possibly phenytoin. So far, most of the investigations available suggest that fetal exposures to lamotrigine or levetiracetam are safer with regard to cognition when compared with other AEDs. Studies on carbamazepine show contradictory results, but most information available suggests that major poor cognitive outcomes should not be attributed to this medication. Overall, children exposed to polytherapy prenatally appear to have worse cognitive and behavioral outcomes compared with children exposed to monotherapy, and with the unexposed. There is an increase risk of neurodevelopmental deficits when polytherapy involves the use of valproate versus other agents.
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Affiliation(s)
- Naymee J Velez-Ruiz
- Department of Neurology, Emory University, 1365 Clifton Rd., Clinic A, 2nd Fl., Atlanta, GA, 30322, USA,
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El-Ibiary SY, Raney EC, Moos MK. The pharmacist's role in promoting preconception health. J Am Pharm Assoc (2003) 2015; 54:e288-301; quiz e301-3. [PMID: 25107285 DOI: 10.1331/japha.2014.14536] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To review the pharmacist's role in preconception health. DATA SOURCES PubMed search using the terms preconception, immunizations, epilepsy, diabetes, depression, tobacco, asthma, hypertension, anticoagulation, pharmacist, pregnancy, and current national guidelines. DATA SYNTHESIS Preconception health has become recognized as an important public health focus to improve pregnancy outcomes. Pharmacists have a unique role as accessible health care providers to optimize preconception health by screening women for tobacco use, appropriate immunizations, and current medication use. Counseling patients on preconception risk factors and adequate folic acid supplementation as well as providing recommendations for safe and effective management of chronic conditions are also critical and within the scope of practice for pharmacists. CONCLUSION Pharmacists play an important role in medication screening, chronic disease state management, and preconception planning to aid women in preparing for healthy pregnancies.
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Wen X, Meador KJ, Hartzema A. Antiepileptic drug use by pregnant women enrolled in Florida Medicaid. Neurology 2015; 84:944-50. [PMID: 25653296 PMCID: PMC4351665 DOI: 10.1212/wnl.0000000000001304] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 11/03/2014] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The study aims were to investigate secular trends in antiepileptic drug (AED) use in women during pregnancy, and to compare the use of first- and second-generation AEDs. METHODS Study participants consisted of female Florida Medicaid beneficiaries, older than 15 years, and pregnant within the time period 1999 to 2009. Fifteen AEDs were categorized into first and second generation of AEDs. Continuous use of AEDs was defined as at least 2 consecutive AED prescriptions totaling more than a 30-day supply. Polytherapy was defined as 2 or more AEDs continuously used for at least 30 overlapping days. Annual prevalence was estimated and compared. RESULTS We included 2,099 pregnant women who were enrolled in Florida Medicaid from 1999 to 2009 and exposed to AEDs during pregnancy. Although there were fluctuations, overall AED use in the study cohort did not increase from 2000 to 2009 (β ± standard error [SE]: -0.07 ± 0.06, p = 0.31). The use of first-generation AEDs decreased (β ± SE: -6.21 ± 0.47, p < 0.0001), whereas the use of second-generation AEDs increased (β ± SE: 6.27 ± 0.52, p < 0.0001) from 2000 to 2009. AED use in polytherapy did not change through the study period. Valproate use reduced from 23% to 8% in the study population (β ± SE: -1.61 ± 0.36, p = 0.0019), but this decrease was only for women receiving an AED for epilepsy and was not present for other indications. CONCLUSION The second-generation AEDs are replacing first-generation AEDs in both monotherapy and polytherapy. Valproate use has declined for epilepsy but not other indications. Additional changes in AED use are expected in future years.
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Affiliation(s)
- Xuerong Wen
- From the Department of Medicine (X.W.), and Department of Pharmaceutical Outcomes and Policy, College of Pharmacy (A.H.), University of Florida, Gainesville; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA.
| | - Kimford J Meador
- From the Department of Medicine (X.W.), and Department of Pharmaceutical Outcomes and Policy, College of Pharmacy (A.H.), University of Florida, Gainesville; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Abraham Hartzema
- From the Department of Medicine (X.W.), and Department of Pharmaceutical Outcomes and Policy, College of Pharmacy (A.H.), University of Florida, Gainesville; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
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Putta S, Pennell PB. Management of epilepsy during pregnancy: evidence-based strategies. FUTURE NEUROLOGY 2015; 10:161-176. [PMID: 30774557 DOI: 10.2217/fnl.15.4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Child-bearing years are often the most precarious management period in the life of a woman with epilepsy. This article reviews the results of many different studies with findings that enable the healthcare team to make confident decisions and recommendations during these critical periods. Preconceptional planning, effective contraception and folic acid supplementation are important fundamentals in preparation for pregnancy. There is growing evidence to avoid valproic acid use during the child-bearing years. Emerging data on congenital malformations and neurocognitive outcomes are available for some of the second-generation antiepileptic drugs and appear reassuring for lamotrigine and levetiracetam. Also reviewed are the benefits of postpartum drug tapers and favorable breastfeeding facts. Counseling the mother and her family on medication choices enables the healthcare team to implement informed decisions that are beneficial for the mother and child.
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Affiliation(s)
- Swapna Putta
- Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Page B Pennell
- Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.,Division of Women's Health, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Passarelli V, de Figueiredo NSV, Moraes Angst DB, Baldocchi MA, Guimarães Rocha MS. Folate use in women with epilepsy: predictors of adherence in a specialized tertiary outclinic. Epilepsy Behav 2015; 43:74-6. [PMID: 25561381 DOI: 10.1016/j.yebeh.2014.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 11/29/2014] [Accepted: 12/04/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE OF THE STUDY The aims of this study were to determine the percentage of women with epilepsy (WWE) taking folic acid (FA) in an outpatient epilepsy tertiary hospital at São Paulo, Brazil, and to identify the possible predictors of adherence. METHOD Five hundred seventy-six medical records of patients followed in our service were reviewed. Sixty-six WWE using antiepileptic drugs with age between 16 and 52, sexually active but not in menopausal period, not pregnant, and not sterilized or with vasectomized partners underwent direct interviews with a prestructured questionnaire. Logistic regression with clinical and demographic variables using a stepwise method was performed to identify predictable variables of folate use. RESULTS We found 42.40% of FA intake. Hormonal contraceptive method use was an independent variable negatively associated with adherence to folate. Additionally, educational level was an independent variable positively associated with adherence to folate in WWE above 35years of age. CONCLUSION We found low folate adherence. Improved planning pre-conception for WWE should improve rates of effective folate supplementation.
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Affiliation(s)
- Valmir Passarelli
- Department of Neurology, Hospital Santa Marcelina, São Paulo, SP, Brazil.
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Thursday 5 June 2014. Br J Occup Ther 2014. [DOI: 10.1177/03080226140770s803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Trattamento medico dell’epilessia dell’adulto. Neurologia 2014. [DOI: 10.1016/s1634-7072(14)67975-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Neurosteroids and their role in sex-specific epilepsies. Neurobiol Dis 2014; 72 Pt B:198-209. [PMID: 24960208 DOI: 10.1016/j.nbd.2014.06.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 05/11/2014] [Accepted: 06/14/2014] [Indexed: 01/21/2023] Open
Abstract
Neurosteroids are involved in sex-specific epilepsies. Allopregnanolone and related endogenous neurosteroids in the brain control excessive neuronal excitability and seizure susceptibility. Neurosteroids activate GABA-A receptors, especially extrasynaptic αγδ-GABA-A receptor subtypes that mediate tonic inhibition and thus dampen network excitability. Our studies over the past decade have shown that neurosteroids are broad-spectrum anticonvulsants and confer seizure protection in various animal models. Neurosteroids also exert antiepileptogenic effects. There is emerging evidence on a critical role for neurosteroids in the pathophysiology of the sex-specific forms of epilepsies such as catamenial epilepsy, a menstrual cycle-related seizure disorder in women. Catamenial epilepsy is a neuroendocrine condition in which seizures are clustered around specific points in the menstrual cycle, most often around the perimenstrual or periovulatory period. Apart from ovarian hormones, fluctuations in neurosteroid levels could play a critical role in this gender-specific epilepsy. Neurosteroids also regulate the plasticity of synaptic and extrasynaptic GABA-A receptors in the hippocampus and other regions involved in epilepsy pathology. Based on these studies, we proposed a neurosteroid replacement therapy for catamenial epilepsy. Thus, neurosteroids are novel drug targets for pharmacotherapy of epilepsy.
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Nakken KO, Taubøll E. [Valproate should be avoided in pregnancy]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:144-5. [PMID: 24477142 DOI: 10.4045/tidsskr.13.1350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Jacobsen PE, Henriksen TB, Haubek D, Østergaard JR. Prenatal exposure to antiepileptic drugs and dental agenesis. PLoS One 2014; 9:e84420. [PMID: 24416231 PMCID: PMC3885552 DOI: 10.1371/journal.pone.0084420] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 11/14/2013] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE The aim of the study was to investigate the association between prenatal exposure to AEDs and the risk of dental agenesis and to differentiate between the possible effects of the different drugs used. METHODS Data on 214 exposed and 255 unexposed children, aged 12-18 years, were extracted from the Prescription Database of the Central Denmark Region and North Denmark Region and the Danish Medical Birth Registry. The children's dental charts were examined for the presence of dental agenesis. RESULTS Overall, children exposed to AED in utero had an increased risk of developing dental agenesis, but as a group, the difference was not significant (OR = 1.7; [95% CI: 0.8-3.6]). The risk of developing dental agenesis was three-fold increased (OR = 3.1; [95% CI: 1.3-7.4]) in children exposed to valproate in mono- or in poly-therapy with other AEDs than carbamazepine or oxcarbazepine. The risk was further increased (OR = 11.2; [95% CI: 2.4-51.9]) in children exposed to valproate and carbamazepine or oxcarbazepine in combination. CONCLUSIONS The present study shows that dental agenesis is a potential congenital abnormality that is related to prenatal exposure to valproate, and dental agenesis may be considered a sensitive marker for the teratogenicity of valproate.
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Affiliation(s)
- Pernille E. Jacobsen
- Section of Pediatric Dentistry, Department of Dentistry, Health, Aarhus University, Aarhus, Denmark
| | - Tine B. Henriksen
- Perinatal Epidemiology Research Unit, Department of Pediatrics, Aarhus Universty Hospital, Aarhus, Denmark
| | - Dorte Haubek
- Section of Pediatric Dentistry, Department of Dentistry, Health, Aarhus University, Aarhus, Denmark
| | - John R. Østergaard
- Center for Rare Diseases, Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
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Women with epilepsy planning pregnancy: we can improve outcomes by improving care. Epilepsy Curr 2013; 13:209-10. [PMID: 24348106 DOI: 10.5698/1535-7597-13.5.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Haider B, von Oertzen J. Neurological disorders. Best Pract Res Clin Obstet Gynaecol 2013; 27:867-75. [DOI: 10.1016/j.bpobgyn.2013.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 07/25/2013] [Indexed: 10/26/2022]
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Åberg E, Holst S, Neagu A, Ögren SO, Lavebratt C. Prenatal exposure to carbamazepine reduces hippocampal and cortical neuronal cell population in new-born and young mice without detectable effects on learning and memory. PLoS One 2013; 8:e80497. [PMID: 24244693 PMCID: PMC3828387 DOI: 10.1371/journal.pone.0080497] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Accepted: 10/14/2013] [Indexed: 12/21/2022] Open
Abstract
Pregnant women with epilepsy have to balance maternal and fetal risks associated with uncontrolled seizures against the potential teratogenic effects from antiepileptic drugs (AEDs). Carbamazepine (CBZ) is among the four most commonly used AEDs for treatment of pregnant epileptic women. We previously reported that new-born children had a decreased head circumference after in utero CBZ exposure. This study investigates how prenatal exposure of CBZ influences the number of neurons in new-born and young mouse hippocampus, amygdala and cortex cerebri. Clinical studies describe inconclusive results on if prenatal CBZ treatment influences cognition. Here we investigate this issue in mice using two well characterized cognitive tasks, the passive avoidance test and the Morris water maze test. Prenatal exposure of CBZ reduced the number of neurons (NeuN-immunoreactive cells) in the new-born mouse hippocampus with 50% compared to non-exposed mice. A reduction of neurons (20%) in hippocampus was still observed when the animals were 5 weeks old. These mice also displayed a 25% reduction of neurons in cortex cerebri. Prenatal CBZ treatment did not significantly impair learning and memory measured in the passive avoidance test and in the Morris water maze. However, these mice displayed a higher degree of thigmotaxic behaviour than the control mice. The body weight of prenatally CBZ exposed five-week old mice were lower compared to control mice not exposed to CBZ (p = 0.001). In conclusion, prenatal exposure to CBZ reduces the number of neurons dramatically in areas important for cognition such as hippocampus and cortex, without severe impairments on learning and memory. These results are in line with some clinical studies, reporting that CBZ has minor negative effects on cognition. The challenge for future studies are to segment out what possible effects a reduction of neurons could have on different types of cognition, like intellectual ability and social interaction.
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Affiliation(s)
- Elin Åberg
- Neurogenetics Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden and Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
- * E-mail:
| | - Sarah Holst
- Department of Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Alexandru Neagu
- Neurogenetics Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden and Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Sven Ove Ögren
- Department of Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Catharina Lavebratt
- Neurogenetics Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden and Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
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Morte MI, Carreira BP, Falcão MJ, Ambrósio AF, Soares-da-Silva P, Araújo IM, Carvalho CM. Evaluation of neurotoxic and neuroprotective pathways affected by antiepileptic drugs in cultured hippocampal neurons. Toxicol In Vitro 2013; 27:2193-202. [PMID: 24055897 DOI: 10.1016/j.tiv.2013.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 08/10/2013] [Accepted: 09/11/2013] [Indexed: 11/25/2022]
Abstract
In this study we evaluated the neurotoxicity of eslicarbazepine acetate (ESL), and of its in vivo metabolites eslicarbazepine (S-Lic) and R-licarbazepine (R-Lic), as compared to the structurally-related compounds carbamazepine (CBZ) and oxcarbazepine (OXC), in an in vitro model of cultured rat hippocampal neurons. The non-related antiepileptic drugs (AEDs) lamotrigine (LTG) and sodium valproate (VPA) were also studied. We assessed whether AEDs modulate pro-survival/pro-apoptotic pathways, such as extracellular-regulated kinase (ERK1/2), Akt and stress activated protein kinase/c-Jun N-terminal kinase (SAPK/JNK). We found that neither ESL nor its metabolites, CBZ or LTG, up to 0.3mM, for 24h of exposure, decreased cell viability. OXC was the most toxic drug decreasing cell viability in a concentration-dependent manner, leading to activation of caspase-3 and PARP cleavage. VPA caused the appearance of the apoptotic markers, but did not alter cell viability. ESL, S-Lic and OXC decreased the levels of phospho-ERK1/2 and of phospho-Akt, when compared to basal levels, whereas CBZ decreased phospho-SAPK/JNK and phospho-Akt levels. LTG and VPA increased the phosphorylation levels of SAPK/JNK. These results suggest that ESL and its main metabolite S-Lic, as well as CBZ, LTG and VPA, are less toxic to hippocampal neurons than OXC, which was the most toxic agent.
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Affiliation(s)
- Maria I Morte
- Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal; Department of Life Sciences, Faculty of Science and Technology, University of Coimbra, Coimbra, Portugal
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Jacobsen PE, Henriksen TB, Haubek D, Ostergaard JR. Developmental enamel defects in children prenatally exposed to anti-epileptic drugs. PLoS One 2013; 8:e58213. [PMID: 23520494 PMCID: PMC3592922 DOI: 10.1371/journal.pone.0058213] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 01/31/2013] [Indexed: 11/17/2022] Open
Abstract
Objective Some anti-epileptic drugs (AED) have well-known teratogenic effects. The aim of the present study was to elucidate the effect of prenatal exposure to AED and the risk of enamel defects in the primary and permanent dentition. Methods A total of 38 exposed and 129 non-exposed children, 6–10 years of age, were recruited from the Aarhus Birth Cohort and the Department of Neurology, Viborg Regional Hospital, Denmark. Medication during pregnancy was confirmed by the Danish Prescription Database. All children had their teeth examined and outcomes in terms of enamel opacities and enamel hypoplasia were recorded. Results Children prenatally exposed to AED have an increased prevalence of enamel hypoplasia (11% vs. 4%, odds ratio (OR) = 3.6 [95% confidence interval (CI): 0.9 to 15.4]), diffuse opacities (18% vs. 7%, OR = 3.0; [95% CI: 1.0 to 8.7, p<0.05]), and numerous (>3) white opacities (18% vs. 10%, OR = 2.2; [95% CI: 0.8 to 6.1]) in the primary dentition. In the permanent dentition, an increased risk of numerous (>3) white opacities (34% vs. 12%, OR = 3.3; [95% CI: 1.3 to 8.4]) was found. Conclusions The present study shows that children prenatally exposed to AED have an increased risk of developing numerous teeth with white opacities in their primary and permanent dentition. In addition, they also have an increased risk of developing diffuse opacities and enamel hypoplasia in their primary teeth.
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Affiliation(s)
- Pernille E Jacobsen
- Section of Pediatric Dentistry, Department of Dentistry, Health, Aarhus University, Aarhus, Denmark.
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Najafi M, Sadeghi MM, Mehvari J, Zare M, Akbari M. Progesterone therapy in women with intractable catamenial epilepsy. Adv Biomed Res 2013; 2:8. [PMID: 23930253 PMCID: PMC3732888 DOI: 10.4103/2277-9175.107974] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Accepted: 07/08/2012] [Indexed: 01/11/2023] Open
Abstract
Background: Catamenial epilepsy is a kind of epilepsy, known in this name, when the periodicity of the exacerbation of the seizure is in association with menstural cycle. The present study examined the progesterone effectiveness as a complementary treatment in women with intractable catamenial epilepsy. Materials and Methods: The present study was conducted as a double-blind randomized controlled trial on 38 women with intractable catamenial epilepsy. Patients were assessed in two groups: The case group received in addition to AEDs, two (Mejestrol) 40 mg progesterone tablets in the second half of the cycle from 15th to 25th day. And the control group received in addition to AEDs, two placebo tablets daily. Age, BMI, epilepsy duration, types of the drugs used, progesterone level, and the number of the seizures in 3 months before and after the study were compared. Results: Based on the results of which there was no statistically significant difference in regard to age, BMI, epilepsy duration, types of the drugs used, progesterone level between the case and the control groups (P-value > 0.05). The number of the seizures after treatment has significantly decreased compared to before-treatment state. The degree of decreasing in the case group receiving the progesterone was higher than in the control group receiving the placebo. The difference, thus, is significant, based on statistical tests (P-value = 0.024). Conclusion: Based on the findings of this study using progesterone in women with intractable catamenial epilepsy has a significant effect on the degree of decreasing in the number of the seizures.
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Affiliation(s)
- Mohammadreza Najafi
- Department of Neurology, Isfahan Neuroscience Research Center, Isfahan, Iran
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Abstract
This review describes the neuroendocrinological aspects of catamenial epilepsy, a menstrual cycle-related seizure disorder in women with epilepsy. Catamenial epilepsy is a multifaceted neuroendocrine condition in which seizures are clustered around specific points in the menstrual cycle, most often around perimenstrual or periovulatory period. Three types of catamenial seizures (perimenstrual, periovulatory and inadequate luteal) have been identified. The molecular pathophysiology of catamenial epilepsy remains unclear. Cyclical changes in the circulating levels of estrogens and progesterone (P) play a central role in the development of catamenial epilepsy. Endogenous neurosteroids such as allopregnanolone (AP) and allotetrahydrodeoxycorticosterone (THDOC) that modulate seizure susceptibility could play a critical role in catamenial epilepsy. In addition, plasticity in GABA-A receptor subunits could play a role in the enhanced seizure susceptibility in catamenial epilepsy. P-derived neurosteroids such as AP and THDOC potentiate synaptic GABA-A receptor function and also activate extrasynaptic GABA-A receptors in the hippocampus and thus may represent endogenous regulators of catamenial seizure susceptibility. Experimental studies have shown that neurosteroids confer greater seizure protection in animal models of catamenial epilepsy, especially without evident tolerance to their actions during chronic therapy. In the recently completed NIH-sponsored, placebo controlled phase 3 clinical trial, P therapy proved to be beneficial only in women with perimenstrual catamenial epilepsy but not in non-catamenial subjects. Neurosteroid analogs with favorable profile may be useful in the treatment of catamenial epilepsy.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M Health Science Center, 8447 State Highway 47, MREB Building, Bryan, TX 77807, USA.
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Koo J, Zavras A. Antiepileptic drugs (AEDs) during pregnancy and risk of congenital jaw and oral malformation. Oral Dis 2013; 19:712-20. [DOI: 10.1111/odi.12061] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 10/28/2012] [Accepted: 11/29/2012] [Indexed: 11/28/2022]
Affiliation(s)
- J Koo
- Columbia University College of Dental Medicine New York; New York; NY; USA
| | - A Zavras
- Department of Epidemiology and of Dentistry; Division of Oral Epidemiology & Biostatistics; Dental Public Health; Herbert Irving Comprehensive Cancer Center; Columbia University Medical Center; New York; NY; USA
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Filgueiras CC, Pohl-Guimarães F, Krahe TE, Medina AE. Sodium valproate exposure during the brain growth spurt transiently impairs spatial learning in prepubertal rats. Pharmacol Biochem Behav 2012. [PMID: 23178315 DOI: 10.1016/j.pbb.2012.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The brain is extremely vulnerable to teratogenic insults during the brain growth spurt, a period that starts during the third trimester of human gestation and is characterized by synaptogenesis establishment of neuronal circuits. While the treatment of epilepsy during pregnancy increases the risk of neurodevelopmental disorders in offspring, the consequences of exposure to anticonvulsants during the brain growth spurt remain poorly known. Here we investigate whether exposure to sodium valproate (VPA) during a similar period in rats impairs spatial learning of juvenile rats. Long-Evans rats were exposed to VPA (200mg/kg) or saline solution (SAL) every other day between postnatal day (PN) 4 and PN10. At PN23 and PN30, Morris water maze performance was evaluated during 6 consecutive days. In the group of animals which started their tests at PN23, the VPA exposure impaired both, swimming speed and learning/memory performance. Interestingly, no differences were observed between VPA and control animals tested from PN30 to PN35. Our data suggests that the neurobehavioral deficits caused by VPA exposure during the brain growth spurt are transitory.
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Affiliation(s)
- Cláudio C Filgueiras
- Departamento de Ciências Fisiológicas, Universidade do Estado do Rio de Janeiro, Brazil.
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47
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Management of non-obstetric pain during pregnancy. Review article. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/j.rcae.2012.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Rivera Díaz R, Lopera Rivera A. Manejo del dolor no obstétrico durante el embarazo. Artículo de revisión. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.rca.2012.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Novaes GF, Amado D, Scorza FA, Cysneiros RM. Social behavior impairment in offspring exposed to maternal seizures in utero. J Neural Transm (Vienna) 2012; 119:639-44. [PMID: 22358065 DOI: 10.1007/s00702-011-0751-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2011] [Accepted: 12/02/2011] [Indexed: 02/04/2023]
Abstract
Human and animal models have demonstrated that maternal seizures in utero could be deleterious to the development of the offspring. This study focused on the social behavior of offspring exposed to seizures in utero. A pilocarpine model of temporal lobe epilepsy was induced in female Wistar rats that were mated after the first spontaneous seizure. Early after birth, pups from an epileptic mother were reared by a control mother. To evaluate the influence of the adoption process, two other groups were added: rat pups from control mothers cross-fostered with other control mothers, and rat pups reared by their birth mother. Animals exposed to seizures in utero showed impaired social behavior with no signs of anxiety-like behavior. This study demonstrated that epileptic seizures during pregnancy could be harmful to brain development and may increase the risk of developing neurodevelopmental disorders. The mechanisms underlying the abnormalities of social behavior are not well understood, and further studies in this field are warranted.
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Affiliation(s)
- Gisane Faria Novaes
- Programa de Pós-graduação em Distúrbios do Desenvolvimento, Laboratório de Neurobiologia, Universidade Presbiteriana Mackenzie, Rua da Consolação, 930. Prédio 38, CEP 01302-907 São Paulo, Brazil
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Pong AW, Pal DK, Chung WK. Developments in molecular genetic diagnostics: an update for the pediatric epilepsy specialist. Pediatr Neurol 2011; 44:317-27. [PMID: 21481738 DOI: 10.1016/j.pediatrneurol.2011.01.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 08/31/2010] [Accepted: 01/31/2011] [Indexed: 02/02/2023]
Abstract
The contributions of genetic influences in both rare and common epilepsies are rapidly being elucidated, and neurologists routinely consider genetic testing in the workup of numerous epilepsy syndromes. Trends in patient attitudes and developments in clinical molecular diagnostics will increase interest in, and the availability of genetic tests for, genetic evaluations of epilepsies. We review recent and planned developments in clinical genetic testing platforms, including their indications, strengths, and limitations. We discuss genome-wide microarray methods (i.e., methods to detect copy number variations), karyotypes, and sequence-based testing. We outline the general approach to genetic evaluations of epilepsy, emphasizing the importance of clinical evaluations, and provide online clinical resources. Finally, we present potential social, legal, and financial barriers to genetic evaluations, and discuss concerns regarding clinical utility and recurrence risk. This review provides a practical overview of molecular diagnostics for the neurologist in the genetic evaluation of epilepsies in 2011.
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Affiliation(s)
- Amanda W Pong
- Department of Neurology, Neurological Institute, Columbia University Medical Center, Columbia University, New York, New York 10032, USA.
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