Rapid switching from levetiracetam to brivaracetam in pharmaco-resistant epilepsy in people with and without intellectual disabilities: a naturalistic case control study

BACKGROUND

Approximately one quarter of people with an intellectual disability (PwID) have epilepsy of whom nearly three-quarters are pharmaco-resistant. There are higher reported neuropsychiatric side-effects to anti-seizure medication (ASM) in this group. Levetiracetam (LEV) is a first-line ASM with a stronger association with neuropsychiatric symptoms for PwID than other ASMs. Brivaracetam (BRV) is a newer ASM. Recent studies suggest a beneficial effect of swapping people who experience neuropsychiatric events with LEV to BRV. However, there is limited evidence of this for PwID. This evaluation analyses real world outcomes of LEV to BRV swap for PwID compared to those without ID.

METHODS

We performed a multicentre, retrospective review of clinical records. Demographic, clinical characteristics and reported adverse events of patients switched from LEV to BRV (2016-2020) were recorded at 3 months pre and 6- and 12-month post-BRV initiation. Outcomes were compared between PwID and those without and summarised using cross-tabulations and logistic regression models. A Bonferroni correction was applied.

RESULTS

Of 77 participants, 46 had ID and 52% had a past psychiatric illness. 71% participants switched overnight from LEV to BRV. Seizure reduction of > 50% was seen in 40% patients. Psychiatric illness history was predictive of having neuropsychiatric side-effects with LEV but not BRV (p = 0.001). There was no significant difference for any primary outcomes between PwID versus without ID.

CONCLUSIONS

Switching from LEV to BRV appears as well tolerated and efficacious in PwID as those without ID with over 90% still on BRV after 12 months.

Mental disorder in adults with intellectual disability. 2: The rate of behaviour disorders among a community-based population aged between 16 and 64 years

Despite the difficulty of defining behaviour disorder, most previous studies have reported a high rate of behaviour disorders in people with intellectual disability (ID). The aim of the present study was to establish the overall rate and types of behaviour disorders in a population-based sample of adults with ID. The other aim was to explore the possible risk factors that are associated with the overall rate as well as different types of behaviour disorders. One hundred and one adults with ID aged between 16 and 64 years were randomly selected from a sample of 246 such adults, i.e. those who were known to the Vale of Glamorgan Social Services Department in South Wales, UK. Thirteen behaviour disorders were rated according to the Disability Assessment Schedule. Background data on subjects were also collected, and were subsequently analysed to assess the relationship between different risk factors and behaviour disorders. Sixty-one subjects (60.4%) had at least one behaviour disorder of any severity or frequency. Twenty-three per cent of subjects showed aggression, 24% self-injurious behaviour, 36% temper tantrum, 26% overactivity, 29% screaming, 38% attention-seeking behaviour, 20% objectionable habits, 18% night-time disturbance and 12% of subjects showed destructiveness. Statistically significant associations were seen between the rate of overall behaviour disorder and the use of psychotropic medication, and between family and group home residence. The rate of aggression was significantly associated with the use of psychotropic medication. The rate of self-injurious behaviour was significantly associated with the severity of ID, female gender and poor communication abilities. The rate of temper tantrum was significantly associated with the use of psychotropic medication. Twenty-four subjects showed severe or frequent aggression, destructiveness, self-injury or temper tantrum, and 11 individuals showed real challenging behaviours. Severe behaviour problems were significantly associated with female gender, severity of ID, the presence of a history of epilepsy and attendance at day activities.

Mental disorder in adults with intellectual disability. 1: Prevalence of functional psychiatric illness among a community-based population aged between 16 and 64 years

The reported prevalence of psychiatric illness among adults with intellectual disability (ID) varies widely between 10 and 39%; however, many methodological problems exist. The aims of the present study were to establish the prevalence of functional psychiatric illness among adults with ID who live in the community, in order to compare the overall rate and types of psychiatric illness between the population with ID and the general population without ID, and to establish the risk factors associated with psychiatric illness in adults with ID. The study was done in two stages. In the first part, a trained psychiatrist interviewed 101 randomly selected adults with ID and their carers using the Mini Psychiatric Assessment Schedule for adults with Developmental Disability (Mini PAS-ADD) to screen for psychiatric caseness. Out of these 101 adults, 90 had sufficient communicative abilities that made the administration of Mini PAS-ADD possible. A second trained psychiatrist interviewed 19 out of the 20 adults who were diagnosed as psychiatric cases according to the initial Mini PAS-ADD interview. This psychiatrist interviewed patients and their carers in line with the full PAS-ADD interview. The second psychiatrist was blind to the initial diagnoses made according to the Mini PAS-ADD questionnaire. A final psychiatric diagnosis was made according to International Classification of Diseases - 10th Revision (ICD-10) criteria. Some 14.4% (95% confidence interval = 7.4-21.4%) of the cohort had a psychiatric diagnosis according to ICD-10 criteria: 4.4% had schizophrenia, 2.2% depressive disorder, 2.2% generalized anxiety disorder, 4.4% phobic disorder and 1% delusional disorder. The overall rate of functional psychiatric illness (point prevalence) was similar to that found in the general population (16%). However, the rates of schizophrenic illness and phobic disorder were significantly higher in the study cohort compared with those in the general population (0.4% and 1.1%, respectively). Increasing age and the presence of physical disability were significantly associated with the occurrence of psychiatric illness. Out of the 11 remaining adults with severe ID, two (18%) had a diagnosis of a psychiatric illness (one mania and one anxiety disorder) according to the Diagnostic Assessment for the Severely Handicapped (DASH) questionnaire.

Identification of a non peptidic RANTES antagonist

A series of phenothiazines demonstrating inhibition of RANTES binding to THP-1 cell membranes has been identified. The lead compound RP23618 (IC50 = 3 microM) was found to inhibit specific binding of 125I-RANTES, but not 125I-MCP-1 to THP-1 cell membranes and furthermore to antagonize RANTES, but not MCP-1-induced chemotaxis of THP-1 cells.

RP 64477: a potent inhibitor of acyl-coenzyme A:cholesterol O-acyltransferase with low systemic bioavailability

RP 64477 (N-butyl-3-(p-decyloxybenzamido)-4-(methylthio)benzamide) has been shown to be a potent inhibitor of the cholesterol esterifying enzyme Acyl-coenzyme A:cholesterol O-acyltransferase (EC 2.3.1.26; ACAT) in intestinal, hepatic, adrenal, and arterial tissue preparations obtained from a range of animal species. Drug concentrations producing 50% inhibition of enzyme activity (IC50 values) ranged from 14-283 nM. Inhibition by RP 64477 in a rabbit intestinal enzyme preparation was shown to be non-competitive with respect to the substrate oleoyl-CoA. In whole cell assays using human intestinal (CaCo-2), hepatic HepG2) and monocytic (THP-1) cell lines, RP 64477 inhibited ACAT activity with IC50s of 113, 503, and 180 nM, respectively. RP 64477 (0.03% w/w by diet) reduced significantly cholesterol absorption in cholesterol/cholic acid-fed rats from 94+/- 8% to 65 +/- 4%. In cholesterol-fed rabbits, cholesterol absorption was reduced from 72 +/- 5% to 50 +/-5% and 44 +/- 5% at dose levels of 10 and 30 mg kg-1 b.i.d., respectively. Plasma cholesterol levels were reduced dose-dependently in both cholesterol/cholic-acid-fed rats and cholesterol-fed rabbits. Neither cholesterol absorption nor plasma cholesterol levels were reduced significantly in animals maintained on standard laboratory diets. Pharmacokinetic studies indicated that RP 64477 were very poorly absorbed following oral administration to rats. Plasma levels of drug were < 2 ng mL-1 following a dose of 2000 mg kg-1 p.o.. When radiolabelled RP 64477 was administered orally, limited absorption was indicated by the overwhelming elimination of radioactivity in the faces (96.4% of administered material) coupled with low renal clearance (0.6% of dose) and biliary excretion (0.05% of dose). In conclusion, this work shows that RP 64477 is a potent inhibitor of ACAT obtained from a range of animal species and man. Inhibition of cholesterol absorption and hypocholesterolaemic activity has been demonstrated in rats and rabbits maintained on diets supplemented with cholesterol. Pharmacokinetic studies indicate low systemic exposure to RP 64477 as a result of limited absorption of this drug.

Nursing in health networks: direction and development

The New York Organization of Nurse Executives and the American Organization of Nurse Executives held an Open Space meeting to examine issues to be addressed by nursing leaders in the development of integrated delivery systems. Participants identified issues related to the role of the RN, clarifying the value nursing adds to health care delivery, and how to articulate nursing's contribution toward patient care quality and outcomes. Action plans were developed for two major goals: operationalizing nursing across multiple settings and within multidisciplinary teams and standardizing measurement in integrated networks.

The estimation of dietary protein intake in chronic renal failure

Forty-five adult clinic patients with chronic renal failure each supplied a 4-day weighed dietary record, a 24-h urine collection, and a nocturnal spot urine sample. Total nitrogen (N) losses derived from the urines were corrected for proteinuria and non-urea nitrogen excretion. Individual estimates of N intake were compared by correlation and assessing the level of agreement. Daily urea N excretion derived from the spot sample correlated well with the 24-h collection P less than 0.001, but the degree of agreement was poor, mean difference being +1.62 g with 95% limits of +5.7 to -2.47 g. The correlation between the spot-sample-derived N loss and dietary N intake was poor, r = 0.42; P less than 0.05. For 12 patients taking a low-protein diet, N intake correlated well with 24-h urine derived N losses, P less than 0.001, mean difference being +0.59 g, 95% limits +2.39 to -1.21 g. The correlation and agreement was less satisfactory for the subjects who had not received dietary instruction, due largely to individual variation in day-to-day protein intake. Use of spot urine samples is too inaccurate for routine clinical practice. Single 24-h urine derived estimates of N intake are only of value for assessing patients previously prescribed a low-protein intake.

Clinical course of recurrent genital herpes and treatment with foscarnet cream: results of a Canadian multicenter trial

Clinic-initiated topical treatment of recurrent genital herpes with foscarnet cream (concentration, 0.3% in men and 1% in women) was compared with a placebo in a Canadian multicenter trial involving 309 patients. Culture-positive episodes of herpes took significantly longer to heal than did the others. Lesions in men were larger and lasted longer but were less symptomatic than those in women. Foscarnet did not statistically improve the times to healing or the loss of symptoms overall but did result in a higher proportion of symptom-free individuals after one day of treatment. Foscarnet-treated patients had a reduced duration of shedding of virus, and this was significant for men. These clinical benefits do not, however, warrant general use of this agent for established lesions. Earlier, prodromal treatment might have been more effective, but patient-initiated studies include a greater proportion of culture-negative (shorter) episodes that often make results difficult to interpret.