Classic ketogenic diet versus further antiseizure medicine in infants with drug-resistant epilepsy (KIWE): a UK, multicentre, open-label, randomised clinical trial

BACKGROUND

Many infancy-onset epilepsies have poor prognosis for seizure control and neurodevelopmental outcome. Ketogenic diets can improve seizures in children older than 2 years and adults who are unresponsive to antiseizure medicines. We aimed to establish the efficacy of a classic ketogenic diet at reducing seizure frequency compared with further antiseizure medicine in infants with drug-resistant epilepsy.

METHODS

In this phase 4, open-label, multicentre, randomised clinical trial, infants aged 1-24 months with drug-resistant epilepsy (defined as four or more seizures per week and two or more previous antiseizure medications) were recruited from 19 hospitals in the UK. Following a 1-week or 2-week observation period, participants were randomly assigned using a computer-generated schedule, without stratification, to either a classic ketogenic diet or a further antiseizure medication for 8 weeks. Treatment allocation was masked from research nurses involved in patient care, but not from participants. The primary outcome was the median number of seizures per day, recorded during weeks 6-8. All analyses were by modified intention to treat, which included all participants with available data. Participants were followed for up to 12 months. All serious adverse events were recorded. The trial is registered with the European Union Drug Regulating Authorities Clinical Trials Database (2013-002195-40). The trial was terminated early before all participants had reached 12 months of follow-up because of slow recruitment and end of funding.

FINDINGS

Between Jan 1, 2015, and Sept 30, 2021, 155 infants were assessed for eligibility, of whom 136 met inclusion criteria and were randomly assigned; 75 (55%) were male and 61 (45%) were female. 78 infants were assigned to a ketogenic diet and 58 to antiseizure medication, of whom 61 and 47, respectively, had available data and were included in the modifified intention-to-treat analysis at week 8. The median number of seizures per day during weeks 6-8, accounting for baseline rate and randomised group, was similar between the ketogenic diet group (5 [IQR 1-16]) and antiseizure medication group (3 [IQR 2-11]; IRR 1·33, 95% CI 0·84-2·11). A similar number of infants with at least one serious adverse event was reported in both groups (40 [51%] of 78 participants in the ketogenic diet group and 26 [45%] of 58 participants in the antiseizure medication group). The most common serious adverse events were seizures in both groups. Three infants died during the trial, all of whom were randomly assigned a ketogenic diet: one child (who also had dystonic cerebral palsy) was found not breathing at home; one child died suddenly and unexpectedly at home; and one child went into cardiac arrest during routine surgery under anaesthetic. The deaths were judged unrelated to treatment by local principal investigators and confirmed by the data safety monitoring committee.

INTERPRETATION

In this phase 4 trial, a ketogenic diet did not differ in efficacy and tolerability to a further antiseizure medication, and it appears to be safe to use in infants with drug-resistant epilepsy. A ketogenic diet could be a treatment option in infants whose seizures continue despite previously trying two antiseizure medications.

FUNDING

National Institute for Health and Care Research.

STAGED VERSUS SIMULTANEOUS APPROACH IN COMPLEX BILATERAL TOTAL KNEE REPLACEMENT: EXPERIENCE FROM TERTIARY INSTITUTION IN NIGERIA

Background

Bilateral end-stage knee osteoarthritis is a common presentation. The decision facing both patient and surgeon is whether to undertake the replacement of both knees in one sitting i.e. simultaneous bilateral total knee replacement (SMTKR) or to undertake this as a staged bilateral total knee replacement (STTKR). The decision is made harder by the presence of severe coronal and sagittal plane deformities and associated bone loss. We present our results of treating such patients with a focus on a trilogy of cost, complication and functional outcome following SMTKR.

Methodology

A retrospective review of 31 patients who presented with bilateral knee arthritis. 19 underwent SMTKR and 12 underwent STTKR. Data on the trilogy of complication, cost and functional outcome were collected and analysed.

Results

Our cohort of patients was overwhelmingly female in both groups at overall F/M = 30/1. Patients in the SMTKR group were slightly younger at a mean of 65 years compared to 69 years in the STTKR group. Mean Oxford Knee Score (OKS) improved significantly in all groups, mean of 54 in SMTKR and 56 in the STTKR groups. There was one fatality in the STTKR from upper GI bleeding and 1 revision for bone graft failure. The overall cost is less with SMTKR.

Summary

SMTKR is a safe and effective undertaking in properly selected patients with bilateral end-stage knee arthritis with severe deformities. Significant experience is however needed to successfully tackle complex deformities and such procedures should be undertaken by experienced arthroplasty surgeons.

Clients' Perception of Maternal, Newborn and Child Health Services received before and during the COVID-19 Outbreak in Nigeria's Epicenter

BACKGROUND

Since the emergence of COVID-19, countries have implemented measures to limit spread, which include movement restrictions. These measures led to poor or inadequate delivery of many health services, including maternal, neonatal and child health (MNCH) services. This study assessed clients' perception of routine MNCH services received from government health care facilities before and during the COVID-19 outbreak in Lagos, Nigeria's epicenter.

METHODS

This was a cross-sectional descriptive study conducted among 1241 women of reproductive age selected by multistage sampling who had just received MNCH services across 12 primary, secondary or tertiary health facilities. Data was collected using interviewer-administered questionnaires and analyzed using STATA version SE15.1.

RESULTS

Before the COVID-19 outbreak, about half of the women perceived waiting time (50.7%), attention given to patients (53.0%), and respect given to patients (55.7%) as somewhat satisfactory. Fiftyfour percent of respondents said access to water was somewhat satisfactory. During the outbreak, 51.0% of the respondents said waiting time at the health facilities was shorter while over a third said attention given to patients (35.8%) and respect given to patients (35.8%) was better. Half of the respondents (50.7%) said access to water remained the same while 47.7% said it was better. Forty-one percent of respondents said overall quality of services became better during the outbreak.

CONCLUSION

To strengthen health systems for MNCH, the government should provide adequate water supply, optimal sanitation and hygiene facilities. Training of staff in provision of patient friendly MNCH services will go a long way to ensure sustained improvement in quality and also perception of care.

Optimal timing of anticoagulation after acute ischemic stroke with atrial fibrillation (OPTIMAS): Protocol for a randomized controlled trial

RATIONALE

Atrial fibrillation causes one-fifth of ischemic strokes, with a high risk of early recurrence. Although long-term anticoagulation is highly effective for stroke prevention in atrial fibrillation, initiation after stroke is usually delayed by concerns over intracranial hemorrhage risk. Direct oral anticoagulants offer a significantly lower risk of intracranial hemorrhage than other anticoagulants, potentially allowing earlier anticoagulation and prevention of recurrence, but the safety and efficacy of this approach has not been established.

AIM

Optimal timing of anticoagulation after acute ischemic stroke with atrial fibrillation (OPTIMAS) will investigate whether early treatment with a direct oral anticoagulant, within four days of stroke onset, is as effective or better than delayed initiation, 7 to 14 days from onset, in atrial fibrillation patients with acute ischemic stroke.

METHODS AND DESIGN

OPTIMAS is a multicenter randomized controlled trial with blinded outcome adjudication. Participants with acute ischemic stroke and atrial fibrillation eligible for anticoagulation with a direct oral anticoagulant are randomized 1:1 to early or delayed initiation. As of December 2021, 88 centers in the United Kingdom have opened.

STUDY OUTCOMES

The primary outcome is a composite of recurrent stroke (ischemic stroke or symptomatic intracranial hemorrhage) and systemic arterial embolism within 90 days. Secondary outcomes include major bleeding, functional status, anticoagulant adherence, quality of life, health and social care resource use, and length of hospital stay.

SAMPLE SIZE TARGET

A total of 3478 participants assuming event rates of 11.5% in the control arm and 8% in the intervention arm, 90% power and 5% alpha. We will follow a non-inferiority gatekeeper analysis approach with a non-inferiority margin of 2 percentage points.

DISCUSSION

OPTIMAS aims to provide high-quality evidence on the safety and efficacy of early direct oral anticoagulant initiation after atrial fibrillation-associated ischemic stroke.Trial registrations: ISRCTN: 17896007; ClinicalTrials.gov: NCT03759938.

Dietary supplementation of Solanum aethiopicum and Solanecio biafrae leaves alters stress and immune responses, antioxidant status, and meat quality in broilers raised in a hot-dry environment

1. This study investigated the influence of dietary supplementation of Solanum aethiopicum and Solanecio biafrae leaves, which have nutraceutical properties, on stress response, cytokine expression, antioxidant status, blood chemistry, abdominal fat and meat quality in broilers reared in a hot, dry environment.2. One day old, Ross 308 chicks (n = 350) were randomly allotted to basal diets containing either no supplement (D1); 2.5 g/kg Solanum aethiopicum leaf (SAL; D2); 5 g/kg SAL (D3); 2.5 g/kg Solanecio biafrae leaf (SBL; D4); or 5 g/kg SBL (D5) for 42 d. Birds were reared at 34 ± 2°C and 40-50% relative humidity for 6 h/d from 22-42 d. Each dietary group was replicated in seven pens containing 10 chicks.3. In the period 1-21 d, body weight gain, feed efficiency and feed intake were not influenced by diet. At 22-42 and 1-42 d, birds supplemented with SAL and SBL had higher (P < 0.05) body weight gain and feed efficiency than the D1 birds. Cloaca temperature, carcase cuts and relative organ weight did not differ between diets. The D3 birds had higher (P < 0.05) erythrocytes and haemoglobin compared with other birds. Dietary supplements reduced (P < 0.05) mortality, abdominal fat, serum total cholesterol, corticosterone, glucose and blood aspartate aminotransferase levels.4. The treatments up-regulated (P < 0.05) splenic intelukin-10, and down-regulated (P < 0.05) tumour necrosis factor-α and interleukin-1β genes. A dose-dependent improvement (P < 0.05) in antioxidant enzyme activities and total antioxidant capacity of serum and breast muscle were found in the supplemented birds. The breast meat of the supplemented birds had lower (P < 0.05) carbonyl and malondialdehyde contents, and higher (P < 0.05) water holding capacity and redness compared with the non-supplemented meat.5. These results illustrated that supplementation with either 5 g/kg SAL or 5 g/kg SBL attenuated the deleterious effects of heat stress in broiler chickens.

Bladder-wall-thickness ultrasound scan in the investigation of LUTS in women: challenges and limitations

Bladder-wall-thickness (BWT) ultrasound assessment in lower urinary tract conditions has been studied extensively for the last 30 years. There is some evidence that it may have diagnostic utility in detrusor overactivity (DO). The cutoff value for BWT for diagnosing DO is still a matter of debate, with different studies using different values. Transvaginal scanning is the most accurate route of measuring BWT, with excellent interobserver variation and reproducibility. There is still ongoing evaluation of bladder ultrasound and its place in the investigation of overactive bladder symptoms.

New nomogram for safe laparoscopic entry to reduce vascular injury

A nomogram is developed to determine the length of Veress needle that could be safely inserted to achieve pneumoperitoneum to reduce the risk of vascular injury during laparoscopic entry. Axial images of magnetic resonance imaging (MRI) were used to measure the vertical distance between umbilicus and retroperitoneal vessels (STR). This distance was correlated with body mass index and a nomogram was developed to exactly measure the safe distance for the length of Veress needle insertion. The fitted equation was STR (skin to rectus sheath) = 31.6 + 3.952 × BMI with adjusted R(2) = 94.5%. The abdominal cavity depth showed a correlation with adjusted R(2) = 84.2%. This showed a significant relation between body mass index and prediction of cavity depth. Using the mean regression line for STP (skin to peritoneum), a safe insertion distance was identified and a nomogram developed which can be used to objectively predict the depth of the peritoneal cavity.

Adenomyosis: Not such an elusive diagnosis any longer

Adenomyosis has been an elusive diagnosis until recently due to the need for a histological confirmation of diagnosis post-hysterectomy. This commentary focuses on the role of non-invasive imaging techniques that have become available for use in the diagnosis of adenomyosis in women with an intact uterus. These include magnetic resonance imaging (MRI) and transvaginal ultrasound (TVS). With improvements in imaging modalities it has now become feasible to establish a diagnosis of adenomyosis without hysterectomy, to exclude additional pathology and to institute conservative symptomatic treatment and monitoring.

Accuracy of magnetic resonance imaging of inguinofemoral lymph nodes in vulval cancer

Inguinofemoral lymphadenectomy contributes to the high morbidity related to surgical treatment of vulval cancer. The objective of this study was to assess the accuracy of magnetic resonance imaging (MRI) in predicting inguinofemoral lymph nodes metastasis in women with vulval cancer. We reviewed the clinical, MRI, surgical, and pathologic findings of 59 women with vulval cancer who were treated at our institution from January 2000 to June 2004. Histology was available for 39 women who had undergone inguinofemoral lymphadenectomy. Clinical and MRI findings were compared with histology result to assess test accuracy. MRI had a positive likelihood ratio (LR+) of 4.8 (95% confidence interval of 2.7-8.6) and negative likelihood ratio (LR-) of 0.17 (0.06-0.49). It had a sensitivity of 85.7% (63.7-97), specificity of 82.1% (69.6-91.1), positive predictive value (PPV) of 64.3% (44.1-81.4), and negative predictive value (NPV) of 93.9% (83.1-98.7). Clinical examination had an LR+ of 6.1 (1.8-21.6) and LR- of 0.69 (0.5-0.96). It had a sensitivity of 35% (15.3-59.4), specificity of 94.3% (84.3-98.8), PPV of 70% (34.7-93.3), and NPV of 79.4% (67.3-88.5). Kappa statistics for interobserver and intraobserver agreement were 0.9091 and 0.8475, respectively. MRI assessment was accurate in predicting negative nodal status that is clinically useful in identifying women who can be spared inguinofemoral lymphadenectomy. It is noninvasive and is superior to clinical assessment. In clinical practice, this should encourage toward nodal sparing surgery, thus lowering surgical-related patient morbidity.

Accuracy of magnetic resonance imaging of inguinofemoral lymph nodes in vulval cancer

Inguinofemoral lymphadenectomy contributes to the high morbidity related to surgical treatment of vulval cancer. The objective of this study was to assess the accuracy of magnetic resonance imaging (MRI) in predicting inguinofemoral lymph nodes metastasis in women with vulval cancer. We reviewed the clinical, MRI, surgical, and pathologic findings of 59 women with vulval cancer who were treated at our institution from January 2000 to June 2004. Histology was available for 39 women who had undergone inguinofemoral lymphadenectomy. Clinical and MRI findings were compared with histology result to assess test accuracy. MRI had a positive likelihood ratio (LR+) of 4.8 (95% confidence interval of 2.7–8.6) and negative likelihood ratio (LR−) of 0.17 (0.06–0.49). It had a sensitivity of 85.7% (63.7–97), specificity of 82.1% (69.6–91.1), positive predictive value (PPV) of 64.3% (44.1–81.4), and negative predictive value (NPV) of 93.9% (83.1–98.7). Clinical examination had an LR+ of 6.1 (1.8–21.6) and LR− of 0.69 (0.5–0.96). It had a sensitivity of 35% (15.3–59.4), specificity of 94.3% (84.3–98.8), PPV of 70% (34.7–93.3), and NPV of 79.4% (67.3–88.5). Kappa statistics for interobserver and intraobserver agreement were 0.9091 and 0.8475, respectively. MRI assessment was accurate in predicting negative nodal status that is clinically useful in identifying women who can be spared inguinofemoral lymphadenectomy. It is noninvasive and is superior to clinical assessment. In clinical practice, this should encourage toward nodal sparing surgery, thus lowering surgical-related patient morbidity.

MRI of vaginal conditions

Magnetic resonance imaging (MRI) has become an important part of the assessment of suspected vaginal pathology. This pictorial review demonstrates the MRI features and some of the histopathological findings of a variety of vaginal conditions. These may be congenital (total vaginal agenesis, partial vaginal agenesis, longitudinal vaginal septum, transverse vaginal septum), benign (Bartholin's cyst, diffuse vaginal inflammation, invasive endometriosis, ureterovaginal fistula, post-surgical appearances with the formation of a neovagina and adhesions) or malignant, usually due to extension or recurrence from another pelvic malignancy. In this paper, examples of the above are described and illustrated together with examples of the much rarer primary vaginal malignancies.

Reducing unnecessary skull radiographs in children: a multidisciplinary audit

AIM

To review guidelines on the indications for skull radiographs with a view to improving compliance and reducing unnecessary irradiation of children.

METHODS

Three audits on the indications, compliance and effect on practice of differing sets of guidelines for skull radiographs following paediatric head trauma were performed. After each audit, alterations in clinical practice with modifications of the guidelines were implemented. The effect of these changes on radiological practice and patient care were recorded. Audits were performed for 3 months (February-April) in 1999, 2001 and 2003.

RESULTS

The number of children with head injuries presenting was unchanged. The number of skull radiographs performed fell from 146 in 1999 to 95 in 2001 and 50 in 2003. Compliance with hospital guidelines increased from 85% in 1999 to 100% in 2003. No neurosurgical problems were missed.

CONCLUSION

The implementation of guidelines that are acceptable to all specialties will improve compliance and reduce unnecessary radiographs being performed. The involvement of the radiography staff will help maintain compliance. The training of junior staff and maintaining good communication with involved departments will improve patient care.