Effect of Prophylactic Phenobarbital on Seizures; Encephalopathy and Mortality in Neonates with Perinatal Asphyxia

Background. Seizures after an asphyxial insult may result in brain damage in neonates. Prophylactic phenobarbital may reduce seizures.Objective. To determine the effect of prophylactic phenobarbital on seizures; death and neurological outcome at hospital discharge.Methods. Neonates with base deficit 16 mmol/l and Apgar score at 5 minutes 7 or requiring resuscitation for 5 minutes at the time of birth were randomised to prophylactic phenobarbital 40 mg/kg (n=50) or placebo (controls) (n=44) within the first 6 hours of life. They were monitored for clinical seizures; hypoxic ischaemic encephalopathy (HIE) and mortality.Results. Seizures developed in 30.0 of the phenobarbital group as opposed to 47.7 of the control group (relative risk 0.63; 95 confidence interval -0.37 - 1.06; p=0.083). The proportions of patients who had died and/or had HIE II or III at time of discharge from hospital were similar in the two groups (42.0 v. 45.5). There were no differences in mortality between the two groups (14.0 v. 15.9). Conclusion. In infants with asphyxia; prophylactic phenobarbital does not reduce the incidence of seizures; HIE and mortality

Overcoming Barriers to Anti-Epileptic Treatment Life Sentence?

Epilepsy; like many other mental illnesses; is more prevalent than is commonly acknowledged.Moreover; its social and economic burden is excessive for the individual; family; health system and country at large. People with epilepsy have low quality of life and productivity. They and their families are stigmatized and discriminated against. Doctors with Africa - CUAMM; has operated aproject for epilepsy treatment together with the local health authorities in Nebbi and Arua districts since 2005; aimed at increasing access to free; effective anti-epileptic medicines. Despite the availability of the medicines; the attendance of many enrolled patients has been erratic. This study was done to document the level of adherence to treatment; the reasons for the observed healthseeking pattern and to assess the feasibility of sustainability of enhanced epilepsy treatment services once the project ended. Retrospective analysis of records of all patients registered in 2004 and 2005 was done in order to determine the level and pattern of adherence. A cross-sectional survey of 93 patients; selected according to the documented patterns of clinic attendance; was done to investigate the reasons for the observed pattern of healthcare use. Assessment of feasibility of sustainability was done by interviewing key informants and eviewing records of expenditures on anti-epileptic medicines for 2005.Conducted in 2006; the study shows that about 84.5of the enrolled patients missed at least one appointment over the two-year period of follow-up; with about one third missing all the clinics since enrolment. A typical patient missed about 60of all the appointments.The overall attendance level at any given time was at a low 40(30for those registered in 2005 and 50for those registered in 2004).There was wide variation in the magnitude and frequency of defaulting at the different sites.Younger and older patients defaulted more often than the middle-aged groups; just as female patients defaulted more frequently than the male counterparts.The reasons for the poor compliance were multiple; patient-specific and often acting simultaneously.The most critical and cross-cutting included distance from the health facility; family support; persistent health education and individual patient/family counseling.The mobilisers (often epilepsy patients themselves) were pivotal in patient/family education and counseling as well as reminding patients about clinic days.The most important adherence-promoting health systems factors were the regular availability of effective medicines and the vertical nature of the delivery system.There were several constraints working against sustainability of enhanced epilepsy care; including technical competence of the health workers; regulatory limitations that forbid the use of some anti-epileptic medicines at some levels of health care; negative staff attitude and high investment levels in ensuring constant availability of anti-epileptic medicines

Phenobarbitone in young children with severe falciparum malaria

The mortality of cerebral malaria (CM) in children remains 10-40; and seizures have been shown to effect outcome adversely. Phenobarbitone (PB) is cheap; widely available in Kenya and reduces the incidence in adults with CM (single IM dose; 3.5 mg kg-1. Its value in children with CM is unkown. We have studied the pharmacokinetics and effect of PB in children with CM as a dose-finding exercise prior to controlled trial. 14 children entered the treatment group and 39 entered the control group. Over the first 6 h; the motor component of the coma score improved in 29 of the treatment group and 26 of the controls; was unchanged in 36 and 51; worsened in 7 and 8; and was not available in 29 and 13 respectively. The time taken to localise pain was 21 + 19 h (x+SD) in the treatment group; and 22 + 14 h in the control. There was no difference between the groups in the incidence of seizure; number of seizures during admission; incidence of neurological sequelae or mortality. Peak PB concentrations exceeded 15 mgL-1 in only 27 of patients. Prophylactic PB (10 mg/kg) has neither apparent benefit nor risk in young children with CM.; probably because of the low blood concentrations achieved