Effects of Carbamazepine and Valproate on Serum Aspartate Aminotransferase, Alanine Aminotransferase and Gamma - Glutamyltransferase in Children

Introduction:

Epilepsy is one of the most common neurological diseases in childhood and adolescence. Carbamazepine (CBZ) and valproate (VPA) have been widely used as the first generation of antiepileptic drugs (AED).

Aim:

The aim of the study has been to evaluate and compare the effect of CBZ and VPA monotherapy on aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyltransferase (GGT) serum levels in children.

Material and methods:

The study has included 100 patients (boys 57/girls 43, age range 1 to 18 years), who have been treated with CBZ or VPA, as initial monotherapy, for at least 12 months. Patients with liver lesions or patients who have been treated with other drugs have been excluded from the study. The initial serum enzyme levels (AST, ALT and GGT) and after 12 months of treatment have been compared.

Results:

53/100 (53%) patients have been treated with CBZ and 47/100 (47%) patients have been treated with VPA.The initial level of enzymes were within the referece range. After one year-long treatment AST was elevated at 4/53 (7.5%) CBZ patients and 9/47 (19.15%) VPA patients (x2 test =3.965, p<0.05). ALT was elevated at 5/53 (9.4%) CBZ patients and 9/47 (19.15%) VPA patients (x2 test =6.953, p<0.05). GGT was elevated at 18/53 (34%) CBZ patients and 7/47 (14.9%) VPA patients (x2 test =4.831, p<0.05).

Conclusion:

The levels of enzymes AST and ALT have been elevated statistically significant in VPA group and GGT in CBZ group.

Neurodevelopmental Follow Up After Therapeutic Hypothermia for Perinatal Asphyxia

Introduction:

Neuroprotective benefit of therapeutic hypothermia in term newborns with hypoxic-ischemic encephalopathy (HIE) was assessed by analyzing survival and neurodevelopmental outcome of neonates subjected to this procedure.

Material and methods:

Newborns with gestational age > 36 weeks and < 6 hours of age with moderate to severe asphyxial encephalopathy underwent cooling protocol at a temperature of 33.5 °C for 72 hours and rewarming period of 6 hours. Outcome measures assessed were death and neurodevelopmental characteristics, which were compared at the different age using ASQ-3. Twenty-five children were assessed at age 3-6, 12-18 and 24-36 months. Median gestational age was 40 weeks, birth weight 3470 g, Apgar score 2/4 and pH on admission to the hospital 7.02. Four (16%) children died.

Results:

At the first assessment developmental categories of communication were normal in 78.9%, problem solving in 63.2%, personal-social in 68.4%, gross motor in 68.4%, and fine motor in 42.1% with a high need of retesting in this area. Second assessment was done in 17 patients: developmental categories of communication normal in 58.8%, problem solving in 70.6%, personal-social in 64.7%, gross motor in 64.7%, and fine motor in 35.3%. Third evaluation was done in 14 patients: developmental categories of communication were normal in 64.3%, problem solving in 71.4%, personal-social in 57.1%, gross motor in 64.3%, and fine motor in 42.9%.

Conclusion:

There was no correlation between baseline parameters and outcome. Results of the study are showing that therapeutic hypothermia in term newborns can provide better survival and less neurologic sequels in HIE patients.

Brain Lesions in Children with Unilateral Spastic Cerebral Palsy

Introduction:

Unilateral spastic cerebral palsy (US CP) is the second most common subtype of cerebral palsy.

Aim:

The aim of the study was to analyze neuroimaging findings in children with unilateral spastic cerebral palsy.

Material and methods:

The study was hospital based, which has included 106 patients with US CP (boys 72/girls 34, term 82/preterm 24). Neuroimaging findings were classified into 5 groups: Brain maldevelopment, predominant white matter injury, predominant gray matter injury, non specific findings and normal neuroimaging findings.

Results:

Predominant white matter lesions where the most frequent (48/106,45.28%; term 35/preterm 13), without statistically significant difference between term and preterm born children (x2=0.4357; p=0.490517). Predominant gray matter lesions had 32/106 children, 30.19%; (term 25/preterm 7, without statistically significant difference between term and preterm born children (x2=0.902; p=0.9862). Brain malformations had 10/106 children, 9.43%, and all of them were term born. Other finding had 2/106 children, 1.89%, both of them were term born. Normal neuroimaging findings were present in14/106 patients (13.21%).

Conclusion:

Neuroimaging may help to understand morphological background of motor impairment in children with US CP. Periventricular white matter lesions were the most frequent, then gray matter lesions.

Plasmapheresis in Pediatric Intensive Care Unit

Introduction:

Plasmapheresis also known as a therapeutic plasma exchange (TPE) is extracorporeal procedure by which individual components of plasma that are harmful or blood cells can be removed from organism by using a blood separation technology.

Aim:

To present the results of the implementation of plasmapheresis in children in the Department of Pediatric Intensive Care of Pediatric Clinic, Clinical center of Sarajevo University, Bosnia and Herzegovina.

Patients and methods:

Research (period from December 2011 to June 2016) analyzed 66 plasmapheresis (11 patients–6 plasmapheresis per patient).

Results:

Out of 11 patients, 7 (63.6%) were girls and 4 (36.4%) were boys. The average age of patients was 11.6 ± 3.9 years (the youngest patient had 4 years and 7 months, while the oldest had 16 years and 10 months). Plasmapheresis were significantly more often done in the winter and summer. Underlying disease was in 54.5% of cases of neurological origin. The treatment was in form of receiving IVIG in 7 patients, or the application of mechanical ventilation in 6 patients. The most common complication was hypotension, which occurred in 45.5% of patients, followed by bleeding in 36.3%, hypercoagulability in 27.2% of patients and hematoma in 27.2% of patients. Lethal outcome occurred in 3 (27.2%) patients.

Conclusion:

Plasmapheresis represents an invasive method due to need for placement of centralized venous catheter that provides adequate blood flow during the procedure. Although complications can be serious, they are rare and are mainly related to the presence of central venous catheter, hemostasis disorders due to use of anticoagulant therapy, and hypotension of the cardiovascular system. It should be noted that for success of plasmapheresis in children multidisciplinary approach is necessary (children’s nephrologist, neuropediatrician, intensive care doctor) as well as well-trained team of doctors and nurses with the acquired knowledge and skills.

Predictors of Mortality in Neonates with Seizures; a Prospective Cohort Study

Objective:

The aim of this study was to analyze prognostic indicators for mortality in neonates with seizures in a level III Neonatal Intensive Care Unit (NICU).

Patients and methods:

A cohort of 100 neonates with clinically manifested seizures hospitalized in the NICU during 4 years period was prospectively monitored for the first year of life. The cohort consisted of 33 preterm and 67 full-term babies with 60 male and 40 female infants.

Results:

The mortality rate in the first year of life of infants with seizures in the neonatal period was 23%. The most common cause of seizures was birth asphyxia for full-term infants and intra-periventricular hemorrhage for preterm infants. Death was more common in pre-term than term infants (p <0,005). Simple regression demonstrated statistically significant associations between death in the first year of life and a cluster of highly associated variables: resuscitation (p<0, 01), mechanical ventilation (p<0,01) and asphyxia (p<0,05). This cluster of variables significantly correlates with: gestational age (p<0, 05), birth weight (p<0, 05) and intracranial hemorrhage (p<0, 05).

Conclusion:

In this cohort of neonates with seizures asphyxia requiring neonatal resuscitation was the primary risk factor for death.

Interictal Electroencephalography (EEG) Findings in Children with Epilepsy and Bilateral Brain Lesions on Magnetic Resonance Imaging (MRI)

INTRODUCTION

Neuroimaging procedures and electroencephalography (EEG) are basic parts of investigation of patients with epilepsies.

AIM

The aim is to try to assess relationship between bilaterally localized brain lesions found in routine management of children with newly diagnosed epilepsy and their interictal EEG findings.

PATIENTS AND METHODS

Total amount of 68 patients filled criteria for inclusion in the study that was performed at Neuropediatrics Department, Pediatric Hospital, University Clinical Center Sarajevo, or its outpatient clinic. There were 33 girls (48,5%) and 35 boys (51,5%). Average age at diagnosis of epilepsy was 3,5 years.

RESULTS

Both neurological and neuropsychological examination in the moment of making diagnosis of epilepsy was normal in 27 (39,7%) patients, and showed some kind of delay or other neurological finding in 41 (60,3%). Brain MRI showed lesions that can be related to antenatal or perinatal events in most of the patients (ventricular dilation in 30,9%, delayed myelination and post-hypoxic changes in 27,9%). More than half of patients (55,9%) showed bilateral interictal epileptiform discharges on their EEGs, and further 14,7% had other kinds of bilateral abnormalities. Frequency of bilateral epileptic discharges showed statistically significant predominance on level of p<0,05. Cross tabulation between specific types of bilateral brain MRI lesions and EEG finding did not reveal significant type of EEG for assessed brain lesions.

CONCLUSION

We conclude that there exists relationship between bilaterally localized brain MRI lesions and interictal bilateral epileptiform or nonspecific EEG findings in children with newly diagnosed epilepsies. These data are suggesting that in cases when they do not correlate there is a need for further investigation of seizure etiology.

Usefulness of laboratory data in estimation of Crohn's disease activity

Crohn's disease (CD) is a chronic inflammatory disease characterized by unpredictable and severe course. Most clinicians use simple laboratory parameters of inflammatory activity such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), the number of leukocytes (Le) and platelet count to assess disease activity. The aim of this paper was to determine the value of various laboratory parameters in the assessment of Crohn's disease activity. The study included 36 patients, 15 men and 21 women, treated for Crohn's disease at the Gastroenterohepatology Clinic, Clinical Centre, University of Sarajevo, in period 2006 and 2007. Assessed patients were divided into three groups, according to the degree of disease activity, which was determined using the Crohn's Disease Activity Index (CDAI). Mild disease (MD) was present in 15, moderately severe disease (MSD) in 14, and severe disease (SD) in 7 patients. Statistical significance of association between values of laboratory parameters with the degree of severity of illness was investigated using the 95% Confidence Interval test. CRP showed a statistical significance for the relationship between MD-MSD (95% CI 6,645-74,333) and the relationship between MD-SD (95% CI 4,114-135,278), while the relationship between MSD-SD was not statistically significant. MPV showed statistical significance only for the relationship between MD-MSD (95% CI 0,060-2,909). Sedimentation rate and the number of red blood cells showed statistical significance for the relationship MD-SD (95% CI 10,638-62,943 and 0,077-1,080). Haemoglobin, hematocrit and platelet count showed statistical significance for the relationship between MD-MSD and MD-SD. Number of leukocytes did not show any statistically significant relationship with clinical activity of disease. The most reliable indicators of activity of Crohn's disease in this study were CRP, MPV, haemoglobin, hematocrit and platelet count, while leukocyte number did not correlate with disease activity. Neither parameter was sensitive enough to distinguish the relationship between moderately severe disease and severe disease. Until finding a "gold standard" for assessment of clinical disease activity, various laboratory and other parameters must be combined and compared with other indicators, such as endoscopic findings and radiological results.

Outcome of patients with infantile spasms

PURPOSE

To assess outcome of children diagnosed with infantile spasms (IS) during the six-year-period (2002-20006), at the Pediatric Clinic of Clinical Center of University of Sarajevo, as well as to present other important clinical characteristics in this group of patients.

METHODS

All patients had medical histories with detailed description orvideo recordings of their seizures, as well as profound neurological exam, series of video-EEG registrations, neuroimaging studies and laboratory studies that were possible to perform.

RESULTS

Total of 19 patients with IS were treated (14 male, 5 female). Etiologically symptomatic IS were present in 78.9% of cases, cryptogenic in 21.1%. Flexor and mixed spasms were the most common (47.4% and 31.6% respectively). Therapeutic response was satisfactory: 42.1% of patients were seizure-free, 47.4% had partial response with more than 50% decrease of seizures, 10.5% had poor therapeutic response. Most of the patients were treated with polytherapy. The follow-up period was 15-70 months (mean 42.5 months). At last check-up four patients had normal development and were without seizures, two were lost to follow-up, two patients have died (21.4%, 10.5% and 10.5% respectively). Out of remaining patients seven (36.8% of total) had a severe psychomotor retardation with spastic tetraparesis, while the rest had hemiparesis and developmental difficulties.

DISCUSSION

Treatment of infantile spasms presents a great challenge, especially in the developing countries like Bosnia and Herzegovina in which the treatment modalities are limited. Our results indicate that despite the lack of the proper treatment options, outcome of the patients regarding control of seizures and latter psychomotor development did not differ significantly from the reports from the other countries.

CONCLUSION

Although prognosis for most patients with infantile spasms remains poor, further studies identifying predictors of favorable prognosis and recent advances in understanding the pathophysiology of infantile spasms offer hope of safer and more-effective therapies that improve long-term outcome.

Use of lamotrigine in medically intractable epilepsies in children

Medically intractable epilepsies are defined as seizures that are not controlled after an adequate trial with 2 first-line antiepileptic drugs (AED). Evidence in the literature show that these patients have many dysfunctions in their lifes. Lamotrigine is part of group of "newer antiepileptic drugs". Goal of this paper was to show what benefit is expected with introduction of add-on therapy with lamotrigine in patients with medically intractable epilepsies. Study was done in period 2002-2007 at Paediatric Hospital in Sarajevo. Inclusion criteria were: established diagnose of epilepsy, medical intractability defined as seizures not controlled after an adequate trial with 2 first-line antiepileptic drugs, age of more than 2 years and less than 18 years. Total of 61 children were assessed, 35 male and 26 female. Average age was 61.3 months at diagnosis of epilepsy. Add-on therapy with lamotrigine started in average about sixteen months after the diagnosis, with average age at starting the therapy of 77.4 months. Predominant type of seizures were partial seizures (with or without secondary generalization) in 67.20% cases, primarily generalized tonic clonic seizures in 13.11% cases, typical and atypical absences in 11.48% cases and myoclonic seizures in 8.20% cases. Reduction in seizure frequency was very good (76-100% reduction) in 37.70% of patients, good (51-75%) in 21.31%, fair (26-50%) in 9.84 and poor (less than 25%) in 31.14%. Chances of poor outcome were greater in patients with partial seizures. Side effects were noticed in 8.2% patients (6,56% with skin rash). Lamotrigine has showed good efficacy and safety profile. It is providing new efficient and well tolerated options for treatment for medically intractable epilepsies.

Familiar spastic paraplegia presenting in a boy with Klinefelter syndrome--case report

In this case report, the boy with familiar spastic paraplegia, the relatively rare genetic disorder and Klinefelter syndrome that was found during investigation, has been presented. The diagnosis of the disease has been established by anamnesis, clinical features and relevant diagnostic procedures, so the criteria for autosomal dominant type of the familiar spastic paraplegia have been fulfilled. The therapeutic possibilities are limited to the physical therapy and orthopedic treatment of feet deformities.