Bilateral tonic pupil during a migraine attack: a case report / Pupila tônica bilateral durante crise de enxaqueca: relato de caso

INTRODUCTION:Tonic pupil or Adie's pupil occurs due to parasympathetic denervation, and it is characterized by mydriasis with little or no response to light, with pupillary contraction to accommodation. It is caused by eye pathologies, such as infections, trauma, neoplasms, inflammatory diseases, and systemic diseases with autonomic dysfunction. Few cases have been reported of bilateral tonic pupils associated with migraine attacks. CASE REPORT: Our aimed to describe the case of a young female patient with a history of chronic migraine without aura, who presented acutely with bilateral pupillary mydriasis during a migraine attack, characterized as tonic pupil, and to discuss the possible causes of mydriasis during a migraine attack.

INTRODUÇÃO: A pupila tônica ou pupila de Adie ocorre devido à denervação parassimpática e é caracterizada por midríase com pouca ou nenhuma resposta à luz, com contração pupilar à acomodação. É causada por patologias oculares, como infecções, traumas, neoplasias, doenças inflamatórias e doenças sistêmicas com disfunção autonômica. Poucos casos foram relatados de pupilas tônicas bilaterais associadas a crises de enxaqueca. RELATO DE CASO: Nosso objetivo foi descrever o caso de uma paciente jovem, com história de enxaqueca crônica sem aura, que apresentou agudamente midríase pupilar bilateral durante uma crise de enxaqueca, caracterizada como pupila tônica, e discutir as possíveis causas da midríase durante uma crise de enxaqueca. ataque de enxaqueca.

Levetiracetam and Midazolam vs Midazolam Alone for First-Line Treatment of Children With Generalized Convulsive Status Epilepticus (Lev-Mid Study): A Randomized Controlled Trial

Background:Benzodiazepines are the first-line anti-seizure medication (ASM) for generalized convulsive status epilepticus (GCSE), but they fail to end seizures in a third of cases. Combining benzodiazepines with another ASM that acts by a different pathway could be a potential strategy for rapid control of GCSE. Objectives: To evaluate the efficacy of adding levetiracetam to midazolam in the initial treatment of pediatric GCSE. Design: Double-blind randomized controlled trial. Setting: Pediatric emergency room at Sohag University Hospital between June, 2021 and August, 2022. Participants: Children aged between 1 month and 16 years with GCSE lasting more than 5 min. Interventions: Intravenous levetiracetam (60 mg/kg over 5 min) and midazolam (Lev-Mid group) or placebo and midazolam (PlaMid group) as first-line anticonvulsive therapy. Outcome measures: Primary: cessation of clinical seizures at 20- min study time point. Secondary: cessation of clinical seizures at 40-min study time point, need for a second midazolam dose, seizure control at 24-hr, need for intubation, and adverse effects. Results: Cessation of clinical seizures at 20-min occurred in 55 children (76%) in Lev-Mid group compared with 50 (69%) in the PlaMid group [RR (95% CI) 1.1 (0.9-1.34); P=0.35]. No significant difference was found between the two groups regarding the need for a second midazolam dose [44.4% vs 55.6%; RR (95% CI) 0.8 (0.58- 1.11); P=0.18] as well as cessation of clinical seizures at 40-min [96% vs 92%; RR (95% CI)1.05 (0.96-1.14); P=0.49] and seizure control at 24-hr [85% vs 76%; RR (95% CI) 1.12 (0.94-1.3); P=0.21]. Intubation was required for three patients in the Lev-Mid group and six patients in the Pla-Mid group [RR (95%CI) 0.5 (0.13- 1.92); P=0.49]. No other adverse effects or mortality were observed during the 24-hour study timeframe. Conclusion: Combined levetiracetam and midazolam for initial management of pediatric GCSE presents no significant advantage over midazolam alone in cessation of clinical seizures at 20-min.

"Congelei com medo de me contaminar": tratando um caso de TEPT crônico com imobilidade tônica em uma fisioterapeuta da linha de frente na pandemia de COVID-19 / "I froze for fear of contaminating myself": treating a case of chronic PTSD with tonic immobility in a physiotherapist frontline during COVID-19 pandemic

RESUMO Objetivo: Neste estudo relatamos o caso de uma profissional de saúde com vivência de imobilidade tônica (IT) e posterior desenvolvimento de transtorno de estresse pós-traumático (TEPT) crônico em decorrência de trauma laboral por conta da COVID-19 que recebeu tratamento remoto com terapia cognitivo-comportamental focada no trauma (TCC-FT). Métodos: Relato de caso de uma paciente acompanhada por seis meses após o recebimento de TCC-FT remota. Resultados: Paciente do sexo feminino, de 36 anos, fisioterapeuta, que desenvolveu TEPT crônico e experienciou IT por medo da contaminação por coronavírus. As escalas psicométricas demonstraram que a TCC-FT reduziu consideravelmente os sintomas de TEPT e depressão e aumentou o apoio social e a resiliência. De acordo com o relato, o tratamento melhorou a concentração e a motivação, e reduziu o sentimento de culpa, a irritabilidade, a insegurança e o desconforto em lidar com outras pessoas. Conclusão: Este artigo demonstra que traumas decorrentes da COVID-19 podem ser capazes de desencadear IT e exemplifica um favorável desempenho da TCC-FT na melhoria global da saúde mental dos pacientes com TEPT crônico com vivência de IT.

ABSTRACT Objective: In this study, we report the case of a health professional with experience of tonic immobility (TI) and subsequent development of post-traumatic stress disorder (PTSD) as a result of occupational trauma due to COVID-19 who received remote treatment with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Methods: A case report of a patient followed for six months after receiving remote TF-CBT. Results: A 36-year-old female patient, the physiotherapist who developed chronic PTSD and experienced TI for fear of coronavirus contamination. Psychometric scales demonstrated that TF-CBT considerably reduced PTSD and depression symptoms and increased social support and resilience. According to the report, the treatment improved concentration and motivation, and reduced feelings of guilt, irritability, insecurity, and discomfort in dealing with other people. Conclusion: This article demonstrates that trauma resulting from COVID-19 can trigger TI and exemplifies a favorable performance of TF-CBT in the global improvement of the mental health of patients with chronic PTSD who experience TI.

The clinical and neuroelectrophysiological characteristics of patients with sudden unexpected death in epilepsy / 中华神经科杂志

Objective:To investigate the clinical and electrophysiological characteristics of patients with sudden unexpected death of epilepsy (SUDEP).Methods:Using "epilepsy" as the keyword, the relevant cases entered from October 2011 to March 2012 were searched in the database of the Electroencephalogram (EEG) Monitoring Center, Xijing Hospital, the Air Force Military Medical University. Telephone follow-up was conducted for all confirmed epilepsy patients, and for the death cases confirmed by telephone follow-up, the patients identified as consistent with SUDEP diagnosis were included in this study based on their past medical history, clinical data, death details, etc, and their clinical and neuroelectrophysiological characteristics were summarized and analyzed.Results:Among the 1 232 patients who underwent 24-hour video-EEG monitoring during the study period, 354 patients were successfully followed up by telephone interview, of whom 17 patients were died (4.8%), 12 individuals met the diagnosis of SUDEP (7 men, 5 women). The duration of the disease in 9 patients exceeded 10 years. Eight cases presented with focal-bilateral tonic clonic seizures. Nine patients were treated with anti-seizure drug monotherapy. All the 24-hour video EEG of 12 patients were abnormal. There were 8 occasions when the EEG occipital α background rhythm slowed down compared with the standard frequency of peers or was dominated by slow waves. Interictal epileptic discharge (IED) located in temporal lobe were found in 12 EEG records, of which 9 EEG records were found with frontal IED. One of the 12 cases received 24-hour video EEG twice within 6 years, and his EEG background rhythm was significantly slower and the IED region was expanded compared with the first EEG record. At the third year after reexamination of EEG, SUDEP developed in this patient.Conclusions:SUDEP patients have a long course of disease and bilateral tonic-clonic seizure. The interictal EEG shows occipital slow α activity and temporofrontal epileptiform discharges, which may increase the risk of SUDEP.

The COVID-19 pandemic and its impact on mental health of healthcare workers / A pandemia de COVID-19 e seu impacto na saúde mental dos profissionais de saúde

ABSTRACT The COVID-19 pandemic has imposed a health crisis around the world. Health professionals are frequently exposed to stressors that put them at high risk for the development or progression of disabling mental disorders, including posttraumatic stress disorder (PTSD). To understand how pandemic stressors have affected the mental health of healthcare workers, our group conducted a longitudinal and nationwide survey. We investigated the occurrence of traumatic events related to the COVID-19 pandemic and the association between exposure to these events and PTSD symptomatology. Importantly, we also investigated factors that might increase or decrease the risk for PTSD. Depression symptoms were also investigated. The results of the first wave of the project were published in a series of three articles, each focused on different risk or protective factors. The results showed that female sex, young age, a lack of adequate personal protective equipment, social isolation and a previous history of mental illness were consistent predictors of PTSD symptoms. Healthcare workers who reported high levels of peritraumatic tonic immobility, a defensive response that is involuntary, reflexive, and evoked by an intense and inescapable threat, also exhibited an increase in the probability of being diagnosed with PTSD. On the other hand, professional recognition had a negative relationship with PTSD and depression symptoms, emerging as a significant protective factor for psychological health. The identification of protective and risk factors in these situations is crucial to guide the adoption of long-term measures in work environments that will enhance the psychological health of these professionals.

RESUMO A pandemia de COVID-19 impôs uma crise de saúde no mundo. Profissionais de saúde foram frequentemente expostos a estressores que os colocam em alto risco para o desenvolvimento ou progressão de transtornos mentais incapacitantes, incluindo o transtorno de estresse pós-traumático (TEPT). Para entender como esses estressores afetaram a saúde mental desses profissionais, nosso grupo realizou um estudo longitudinal nacional. Investigamos a ocorrência de eventos traumáticos especificamente relacionados à pandemia e a associação entre a exposição a esses eventos traumáticos e a sintomatologia do TEPT. É importante ressaltar que também investigamos fatores que podem aumentar ou diminuir o risco de TEPT. Sintomas de depressão também foram investigados. Os resultados da primeira onda do projeto foram publicados em uma série de três artigos, cada um focado em diferentes fatores de risco ou proteção. Os resultados mostraram que sexo feminino, idade jovem, falta de equipamento de proteção individual adequado, isolamento social e história prévia de doença mental foram preditores consistentes de sintomas de TEPT. Os profissionais de saúde que relataram altos níveis de imobilidade tônica, uma resposta peritraumática involuntária e reflexa evocada em situações de ameaça intensa e inescapável, exibiram aumento na probabilidade de um provável diagnóstico de TEPT. Por outro lado, reconhecimento profissional teve relação negativa com sintomas de TEPT e depressão, emergindo como importante fator de proteção para a saúde mental. Identificar fatores protetores ou de risco nessas situações é fundamental para orientar a adoção de medidas de longo prazo nos ambientes de trabalho que melhorem a saúde mental desses profissionais.

Muito além do trauma: uma investigação sobre o papel das reações peritraumáticas sobre o transtorno de estresse pós-traumático / Beyond the trauma: an investigation of the role of peritraumatic reactions on posttraumatic stress disorder

O Transtorno de Estresse Pós-Traumático (TEPT) é uma condição debilitante que impacta significativamente a qualidade de vida dos seus portadores. Dentre vários fatores de risco para o TEPT, as reações peritraumáticas (RP), como a imobilidade tônica peritraumática (ITP), dissociação (DP) e reações físicas de pânico (RFP), estão entre as mais investigadas. No entanto, a maioria dos estudos avaliou essas RP separadamente, e o elo entre elas e o TEPT ainda não foi bem compreendido. Portanto, essa tese teve como objetivos: (i) estimar simultaneamente o efeito das três RP sobre o TEPT utilizando um instrumento validado; e (ii) avaliar se há efeito indireto da ITP sobre o TEPT mediado pelo sentimento de culpa/vergonha. Utilizamos modelagem de equações estruturais para analisar dados de 3211 participantes do Rio de Janeiro e de São Paulo. Tratamos as RP como variáveis latentes, selecionando desconfundidores específicos para cada reação. Nossas exposições foram as RP, sendo TEPT o desfecho. Calculamos odds ratios e intervalos de confiança de 95%. Utilizamos o Bayesian Information Criterion para comparar o ajuste de modelos não aninhados. Quando analisadas separadamente, todas as RP alcançaram significância estatística. No entanto, apenas DP (ORDP=1,8; IC95%:1,3-2,4) e RFP (ORRFP=2,5; IC95%:1,8-3,4) permaneceram estatisticamente significativas quando incluímos as três reações em um modelo com seus respectivos desconfundidores e correlações entre elas. Os resultados sugeriram um possível efeito da ITP sobre o TEPT (ORITP=1,4; IC95%:1,0-1,9). As interações entre as RP não foram estatisticamente significativas. Ao investigarmos o sentimento de culpa/vergonha como mediador entre ITP e TEPT, o efeito indireto alcançou apenas significância estatística limítrofe (ORITP(TNIE)=1,1; IC95%:1,0-1,2). Os efeitos direto (ORITP(PNDE)=1,3; IC95%: 0,8-1,8) e total (ORITP(TE)=1,4; IC95%:0,9-1,9) para ITP perderam significância quando todas as RP, seus desconfundidores e correlações entre elas fizeram parte do mesmo modelo. As demais RP, no entanto, permaneceram estatisticamente significativas (ORDP=1,7; IC95%:1,3-2,3 e ORRFP=2,5; IC95%:1,8-3,4). Nossos resultados mostraram que a DP e as RFP aumentaram o risco de TEPT mesmo quando consideradas em conjunto. A ITP pode ter efeito sobre o risco de TEPT, mas esse achado deve ser interpretado com cautela devido a significância limítrofe dessa RP em nosso modelo final. Também não identificamos uma mediação significativa entre ITP e TEPT pelos sentimentos de culpa/vergonha. Contudo, a significância limítrofe encontrada para o efeito indireto demanda investigações adicionais. Nossos achados reforçam a ideia de que as reações peritraumáticas devem ser analisadas e compreendidas como ocorrências simultâneas. Também seria oportuno que estudos envolvendo culpa/vergonha, ITP e TEPT focalizassem traumas caracterizados por aprisionamento e impossibilidade de escapar, dado que estas experiências são apontadas como mais susceptíveis para desencadear a ITP. (AU)

Posttraumatic stress disorder (PTSD) is a debilitating condition that greatly impacts quality of life. Among several PTSD risk factors, peritraumatic reactions (PR) such as peritraumatic tonic immobility (PTI), dissociation (PD) and physical panic reactions (PPR) are some of the most investigated. However, several studies have assessed these PR separately, and the pathway connecting them to PTSD is not well understood. Therefore, this thesis aimed to: (i) simultaneously estimate the effect of the three PR on PTSD using a validated instrument; and (ii) assess if there is an indirect effect of PTI on PTSD mediated by feelings of guilt/shame. We used structural equation modelling to analyse data from 3211 participants from Rio de Janeiro and São Paulo. We treated the PR as latent variables and selected specific confounders for each reaction. Our exposures were the PR, and PTSD was the outcome. We calculated odds ratios and 95% confidence intervals for each analysis. We also employed the Bayesian Information Criterion to compare the goodness of fit between non-nested models. Separately, all PR achieved statistically significant results. However, only PD (ORPD=1.8; 95%CI:1.3-2.4) and PPR (ORPPR=2.5; 95%CI:1.8-3.4) remained statistically significant when all three were included in a model with their respective confounders and correlations among all PR. Our findings suggested a possible effect of PTI on PTSD (ORPTI=1.4; 95%CI:1.0-1.9). Interactions between the PR were not statistically significant. When we investigated feelings of guilt/shame as the mediator between PTI and PTSD, the indirect effect achieved a borderline statistical significance (ORPTI(TNIE)=1.1; 95%CI:1.0-1.2). Direct (ORPTI(PNDE)=1.3; 95%CI:0.8-1.8) and total (ORPTI(TE)=1.4; 95%CI:0.9-1.9) effects lost their significance when all PR, their confounders and correlations were included in the same model. The other PR remained statistically significant (ORPD=1.7; 95%CI:1.3-2.3 and ORPPR=2.5; 95%CI:1.8-3.4). Our findings showed PD and PPR to increase the risk of PTSD even when considered in tandem. PTI could have an effect on PTSD, but this must be considered cautiously, as this PR only reached borderline significance in our final model. Feelings of guilt/shame did not significantly mediate PTI's effect on PTSD. However, a borderline statistical significance in the indirect effects warrants further investigation. Our findings reinforce the hypothesis that peritraumatic reactions should be analysed and understood as simultaneous occurrences, not as separate entities. It would also be appropriate for studies concerning guilt/shame, PTI and PTSD to focus on traumas characterized by imprisonment and feelings of inescapability, given that these experiences are allegedly more likely to trigger PTI. (AU)

Tonic Traditional Chinese Medicine Injections Against Cerebral Ischemic Stroke： An Overview of Systematic Reviews/Meta-analyses / 中国实验方剂学杂志

ObjectiveTo re-evaluate the systematic reviews/Meta-analyses （SRs/MAs） of tonic traditional Chinese medicine （TCM） injections against cerebral ischemic stroke （CIS） and provide evidence support for clinical practice and decision-making. MethodTCM injections of different varieties were obtained after searching the three major drug catalogues. Seven Chinese and English databases were searched from database inception to March 13，2022，for the relevant SRs/MAs. The methodological quality，risk of bias，reporting quality，and quality of evidence were assessed by Assessment of Multiple Systematic Reviews-2 （AMSTAR-2），the Risk of Bias in Systematic Review （ROBIS），the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 （PRISMA 2020），and the Grading of Recommendations Assessment，Development，and Evaluation （GRADE）. In addition，the literature overlap matrix was established to calculate the corrected covered area （CCA） and evaluate the rate of overlaps of the original literature. ResultFive types of TCM injections and 18 SRs/MAs were included. AMSTAR 2 evaluation showed that the methodological quality of 18 SRs/MAs was extremely low，and 14 SRs/MAs had a high risk of bias assessed by ROBIS. The quality evaluation results reported by the PRISMA 2020 showed that the scores of the studies included ranged from 19.5 to 28.5，with 10 being of medium quality and eight of low quality. The evaluation with the GRADE system demonstrated that one outcome was moderate-quality evidence，15 outcomes were low-quality evidence，and 41 outcomes were very low-quality evidence. The CCA of the included SRs/MAs was 0.263，indicating a low rate of overlaps of the original literature. ConclusionTonic TCM injections are effective and safe in the treatment of CIS，but this conclusion should be treated with caution because of the low quality of methodology，reports，and evidence in published SRs/MAs. It is recommended to improve the study design，obtain clinical evidence of higher quality，and conduct systematic evaluations in strict accordance with procedures to standardize the reporting of research results.

Corpo próprio e próprio corpo: aproximações entre psicanálise e psicomotricidade / Own body: approaches between psychoanalysis and psychomotricity

Este artigo trata da relação dinâmica da unicidade mãe-bebê, que vivencia todos os cuidados maternos e experiencia múltiplas sensações ofertadas pela preocupação materna primária. O momento inicial de ambiência satisfatória se distingue dos demais, pelo abandono quase total do narcisismo materno, em função da identificação com o bebê, tornando-se, assim, uma mãe suficientemente boa. Neste trabalho, a percepção do corpo e das vivências corporais se relacionam à constituição do psiquismo na fase primária infantil. As experiências do corpo, neste universo de sensações, e o desenvolvimento emocional se fundam à abordagem do diálogo tônico nas tensões emocionais. A teoria de Winnicott, que pinça o cuidado materno sempre que perceptualmente o bebê é pinçado, seja na capacidade perceptual auditiva ou visual, particulariza uma vivência de unidade, com uma dependência absoluta do bebê pelos cuidados da mãe. Estes primados são condições essenciais para os estados de tensão e relaxamento tônicos, em momentos alternados de necessidade e satisfação. Os estados de excitação e tranquilidade do bebê são expressos pela tensão tônica e este tipo de linguagem corporal é especialmente vivenciado pelo infante durante a maternagem, sendo um facilitador da personalização desse sujeito que já existe no mundo.

This article deals with the dynamic relationship of the mother-baby unity, which experiences all maternal care and experiences multiple sensations offered by the primary maternal concern. The initial moment of satisfactory ambience is distinguished from the others by the almost total abandonment of maternal narcissism due to identification with the baby, thus making a mother good enough. In this work, the perception of the body and bodily experiences are related to the constitution of the psyche at this stage. The body's experiences in this universe of sensations and the emotional development at this stage are based on the approach of tonic dialogue in emotional tensions. Winnicott's theory that grasps maternal care whenever the baby is perceptually grasped, whether in the auditory or visual perceptual capacity, we have there, an experience of unity, with an almost absolute dependence of the baby on the mother's care. These cares are essential conditions for tonic states of tension and relaxation, in alternating moments of need and satisfaction. The baby's states of excitement and tranquility are expressed by tonic tension and this type of body language is especially experienced by the infant during motherhood, being a facilitator of the personalization of this subject that already exists in the world.

Carbamazepine-induced hypersensitivity pneumonitis in a patient with neuromyelitis optica: A case report

A 36-year-old female with serum anti-aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (NMOSD) on carbamazepine (CBZ) therapy for paroxysmal tonic spasms (PTS) developed Type 1 respiratory failure. High-resolution computed tomography chest showed diffuse ground-glass opacities in both lungs predominantly in bilateral perihilar region sparing subpleural regions and predominantly upper lobes with a smooth interlobular septal thickening. A transbronchial lung biopsy was consistent with hypersensitivity pneumonitis and following withdrawal of the CBZ and treatment with steroids her respiratory symptoms resolved. After stopping CBZ, PTS recurred, which was successfully treated with lacosamide. This is the first described biopsy-proven case of CBZ-induced hypersensitivity pneumonitis in the NMOSD patient.

A Study Of Clinical Profile And MRI Findings Of Patients Admitted In LG Hospital With New Onset Generalized Tonic Clonic Seizures

Background:Seizure is defined as a paroxysmal event due to abnormal, excessive, hyper synchronized discharge from central nervous system neurons. A generalized tonic clonic seizure is involuntary movements of all limbs that have a tonic phase followed by clonic muscle c ontraction. It has various underlying etiologies.It is a major public health concern in terms of burden of disease,nature of illness, and its impact on individual, family, and community.Objective: This study was performed to evaluate clinical profile and MRI findings of patients admitted in LG Hospital with 1st episode of generalized tonic clonic seizures (GTCS).Design: The study was cross sectional study conducted over a period of 1yr in AMC MET medical college, Ahmedabad.Material And Methods:The clinical profile and MRI findings of 50 patients with 1st episode of GTCS admitted in the medicine department of our hospital were analysed. Result:The most common age group affected was 18-30 yrs (56%), more commonly affecting males (54%). The most common presenting symptoms are uprolling of eyes (90%), followed by frothing from mouth (80%) and tongue bite (78%). AmongMRI findings, the majority of patients (78%) had normal MRI followed by infarct (8%) and tuberculoma (4%). Conclusion:The onset of GTCS occurs most commonly in early adulthood and both male and female genders are almost equally affected. The most common presentation is tonic clonic type of convulsion with uprolling of eyes, frothing from mouth and tongue bite. Majority of patients didn't have any co-morbidities and also had normal laboratory parameters and normal MRI findings. In patients with metabolic precipitating factors; most common was alcohol withdrawal, while in those with CNS cause, the most common MRI finding was infarct.

Trends in Patients with Long COVID (COVID-19 Long-Term Effects) in the Kampo Outpatient Department of Infectious Diseases at Our Clinic — From Early Cases / 日本東洋医学雑誌

In response to the increasing numbers of patients with long-term effects of coronavirus disease 2019 (COVID-19), we started using Kampo (traditional Japanese) medicine for some outpatients. We analyzed the patients' characteristics and the treatments used in each case. Our subjects were 9 patients who visited our clinic between May and September 2021. All subjects provided their written informed consent and were followed for several months. Decoctions or extract formulations were prescribed for treatment based on pattern identification, and general guidance related to lifestyle habits based on traditional thought was also provided. Fatigue, lifestyle of intemperance (due to excessive amounts of cold foods and drinks), and mental/physical stress were present in each patient. Some patients also felt strong anxiety about the lack of any established Western medical treatment and insufficient follow-up systems for patients with long-term effects of COVID-19 (long COVID). Tonic formulas and formulas of involving Bupleuri radix were often used. All 9 patients showed a tendency to improve their symptoms within 4 or 5 weeks of treatment. Our impression is that the prompt effect of Kampo medicine was achieved by combining the use of Kampo medicines with instructions to stop eating excessive amounts of cold foods and/or drinks. Further study is needed in the future. For long COVID, no Western medical treatment has yet been established. On the other hand, in our experience with these patients, Kampo medicine based on the concept of mind-body unity was useful.

Profile of children with seizures in a tertiary care hospital at VCSGGIMS and R Srinagar Pauri, Gharwal, Uttarakhand, India

Background: Seizure is one of the common causes of childhood hospitalization with significant mortality and morbidity. Current study is to find the etiology of seizure and classify seizure into various types and age groups presenting to tertiary center in Department of pediatrics VCSGGIMS and R Srinagar Pauri, Gharwal, Uttrakhand, India.Methods: This was a hospital based prospective study carried out from 1st Jan. 2014 to 31st Dec 2014. Variables collected were demographics, clinical presentations, laboratory tests, brain imaging studies, electroencephalography, diagnosis and hospital course.Results: A total of 276 patients were admitted for seizures with 172 (62.3%) males and 104 (37.7%) females. Among these patients, 148 (53.5%) presented with fever and 157 (56.8%) of children were less than 5 years of age. Generalized tonic-clonic seizure was the most common seizure type (69.2%) followed by partial (19.2%), absence (2.8%), myoclonus (1.6%) and others (6.9%). Seizure disorder (33.7%), febrile seizures (30%), CNS infections (meningitis 6.1%, encephalitis 6.5% and Tubercular meningitis 1.8%) and neurocysticercosis were other common etiologies. Abnormal brain images were noted in 55 (45.45%) out of 121 patients and most common abnormality was neurocysticercosis 33(12%).Conclusions: Acute episode of seizure is one of the causes for hospitalization. It can be concluded from present study that most of seizures caused by febrile seizures and CNS infections (meningitis and encephalitis, neurocysticercosis) can be managed better with prompt interventions. Children presenting with unprovoked seizure need prolonged follow up with neurophysiologic studies and neuroimaging (CT or MRI) for better understanding of childhood seizure.

Aetiology of new onset seizures in cases admitted to an intensive care unit of a tertiary care hospital: a two year study

Background: Seizures are a common neurological disorder encountered globally in regular medical practice. Hospital onset seizures may occur in patients who never had a history of seizure before hospitalization and may be due to causes that lead to hospitalization or acquired during hospitalization like stroke, neuro infection etc. The objectives of this study were the purpose of the present study was to study the incidence and to describe demographic and clinical characteristics of patients developing new onset seizures in an intensive care unit of a tertiary care hospital.Methods: A prospective study for two years was conducted on cases of seizures admitted in an intensive care unit of a tertiary care hospital. The etiology of all the cases was recorded based on the clinical history and necessary investigations like EEG and imaging studies of the brain in cases if required.Results: About 238 cases with males 177 and females 61 cases were enrolled, and 31-50 years was most common age group. Diabetes was the most common co morbidity associated and generalized seizures were most common. CVA was most common etiology (26.89%) and idiopathic next common. Infarct was most common cause of CVA and meningitis in infections. Generalized tonic clonic seizures was most common in cases with CVA as the aetiology followed by infective cases.Conclusions: It is mandatory to deal cautiously and carefully the cases of seizures developing in an ICU in addition to proper history and examination, each patient must undergo detailed EEG, imaging investigations and other ancillary investigations if necessary.

A clinical study of new onset seizures in children aged 3-12 years

Background: Seizures are common in pediatric age group and less than 1/3rd of seizures in children are caused by epilepsy. Aim of present study was to analyze the etiological factors and clinical profile of new onset seizures in children aged 3-12 years.Methods: This was a prospective study done at a tertiary care center of south India. Authors analyzed 98 children aged 3-12 years presenting with new onset seizures. Proper history and investigations including EEG, and CT brain were done to confirm the etiology.Results: Out of 98 children 51 were 3-5 yrs of age and 47 were 6-12 years. 66.3% had generalized seizure and 33.6% had partial seizure. Partial seizure were more common in 5-12 years of age. Intracranial infections were the leading cause (73/98) which included neurotuberculosis (26/73), NCC (20), bacterial meningitis (12), cerebral malaria (8) and viral encephalitis (7). Intracranial infections' were the' leading cause in both age groups. Space occupying lesions were more common in 6-12 years (46.8%) as compared to 3-5 years (19.6%). NCC and Tuberculoma were the leading CT findings in both age groups. There was significantly high incidence of focal EEG changes in partial seizure group compared to generalized seizure group.Conclusions: Intracranial infections were leading cause of new onset seizures especially GTCS. Good clinical evaluation and judicious use of investigations should be ensured. CT brain and EEG are more likely to be informative in partial seizures than in generalized seizures.

Semiological characteristics and clinical application value of bilateral asymmetrical tonic seizures / 中华神经科杂志

Objective To illustrate the semiological characteristics of the three sub-types within the broad bilateral asymmetric tonic seizures (BATS),summarize their predictive values on lateralization and localization of seizure onset zone (SOZ),and analyze the difference between BATS and asymmetrical tonic limb posturing (ATLP).Methods A retrospective review of 385 patients who underwent stereotactic electrode implantation in the Sanbo Brain Hospital,Capital Medical University from September 2011 to May 2018 was performed.As long as there was a clinical epileptic seizure in the presence of BATS or ATLP,the patients were classified into the corresponding groups.Postoperative prognosis was assessed using Engel's grading criteria for a follow-up of no less than six months.Seizure descriptions were based on the classification of epileptic seizures introduced by Lüiders,which used arrows to connect the symptoms in chronological order.Results There was no statistically significant difference between the classic BATS and bilateral proximal tonic seizure in terms of whether it could be an independent seizure,as the onset and end of the seizure,with version and generalized tonic-clonic seizure (P＞0.05).Compared with the ATLP,except for whether it could be an independent seizure (P=1.000) and onset before versive seizure (P=0.068),the BATS showed significantly different semiological features (P＜0.05).The classic BATS and secondary motor area epilepsy had a 100.0％ predictive accuracy on the lateralization of SOZ.In the patients with broad BATS,the SOZ distribution was more extensive,but it was rare in the orbitofrontal gyrus,frontal pole and mesial temporal lobe.Compared with the bilateral proximal tonic seizures from the other regions,those originated from supplementary somatosensory motor area and its adjacent areas were rare and showed no statistically significant difference (0/8 vs 40.0％ (18/45),x2=3.226,P=0.072) but a low trend.The predictive value of BATS on lateralization of SOZ was higher than that of ATLP (84.9％ (45/53) vs 57.1％ (24/42),x2=9.086,P=0.003),and BATS was less originated from temporal lobe than ATLP (3.8％ (2/53) vs 23.8％ (10/42),x2=8.523,P=0.004).Conclusion Different from ATLP,the broad BATS are characterized by tonic proximal upper limb posturing,and have a higher predictive value on lateralization and localization of SOZ.

Study of anticonvulsant activity of acetazolamide on albino rats and its influence on anticonvulsant activity of sodium valproate

Background: Epilepsy is a common neurological disorder. 30-40% of patients will continue to have seizures despite the use of antiepileptic drugs either alone or in combination. The present study is undertaken to evaluate the anticonvulsant activity of Acetazolamide (ACZ) in albino rats and its influence on anticonvulsant activity of sodium valproate.Methods: Albino rats (150-200gms) of male sex were randomly selected, from central animal facility, MMCRI, Mysore. They were divided into 6groups (per model) of 6 rats each, control group-normal saline 0.5ml, standard group-sodium valproate (300mg/kg), dose 1-ACZ (8.75mg/kg), dose 2-ACZ (17.5mg/kg) and dose 3-ACZ (35mg/kg), dose 4-ACZ (8.75mg/kg) with sodium valproate (150mg/kg). The anti-convulsant activity was screened using MES model and PTZ model.Results: Results were analysed by ANOVA followed by post hoc Fisher’s LSD test. The ACZ has shown anticonvulsant activity at the dose of 17.5mg/kg and 35mg/kg body weight and combination of ACZ 8.75mg/kg with sodium valproate 150mg/kg both in MES model and PTZ model. The anticonvulsant activity of ACZ was less when compared to Sodium Valproate in both MES model and PTZ model. The anticonvulsant activity of combination, ACZ 8.75mg/kg with Sodium valproate 150mg/kg was comparable and more significant when compared to standard drug alone in MES model and PTZ model.Conclusions: The ACZ has shown anticonvulsant activity in MES model and PTZ induced seizure model of epilepsy. This study has shown that ACZ potentiated the effect of sodium valproate and can be used as add on drug with sodium valproate in epilepsy.

Evaluation of levetiracetam and valproic acid as monotherapy on quality of life in patients of generalized tonic clonic epilepsy

Background: Quality of life plays an important role in patients of epilepsy and is the most neglected part during management. The antiepileptic drugs treatment results in seizure control but adversely affect the quality of life in patients.Methods: An observational analytical study was conducted in the Department of pharmacology with Department of Neurology of Himalayan Institute of Medical Sciences, Dehradun over 12 months. 85 patients fulfilling the inclusion criteria with diagnosis of generalized tonic clonic seizures (GTCS) were enrolled and divided into two groups based on physicians discretion and followed up for 12 weeks. Patients were evaluated for quality of life by QOLIE-10 self administered questionnaire at 0 and 12 weeks, assessed for seizure control and drug related adverse effects.Results: 85 patients were enrolled and divided into two treatment arms as per physician discretion, levetiracetam (41) and valproic acid group (44). Study drugs showed significant improvement in quality of life, levetiracetam showed mean change that was significantly greater than valproic acid (p=0.003) at 12 weeks. Patients who failed to achieve seizure control at 6 weeks were 17% patients in levetiracetam and 20% in valproic acid group, reason being non-adherence which was 17% and 20% respectively. Adverse events recorded with Levetiracetam (10), most common being increased sleep and with valproic acid (18), with most common being increased sleep and weight gain.Conclusions: Levetiracetam treatment resulted in better quality of life, with similar seizure control but decreased number of adverse effect then Valproic acid.

Síndrome de Lennox Gastaut: Aproximación diagnóstica y avances terapéuticos: Fármacos antiepilépticos, Canabidiol y otras alternativas / Lennox Gastaut Syndrome: Diagnosis approach and therapeutics advances: Antiepileptic drugs, cannabidiol and other alternatives

El Síndrome de Lennox Gastaut es una encefalopatía epiléptica catastrófica de inicio en la infancia con características electro-clínicas definidas de la siguiente manera: 1) presencia de múltiples tipos de crisis epilépticas especialmente tónicas; 2) deterioro cognitivo asociado a cambios conductuales; 3) presencia de complejos punta- onda lenta generalizados en el electroencefalograma (EEG) y paroxismos generalizados de actividad rítmica rápida durante el sueño. Su etiología puede ser estructural o genética (antes denominadas sintomáticas y criptogénicas, respectivamente). El diagnóstico inicial puede ser difícil ya que con frecuencia no se identifican todos los criterios al comienzo del cuadro y el diferencial considera otros síndromes epilépticos de inicio en la infancia, tales como las epilepsias mioclónicas. El tratamiento es muy complejo, se carece de guías definidas de práctica clínica, por lo cual la experiencia de expertos es relevante. Se sugiere inicio de medicación con valproato. Lamotrigina, felbamato, topiramato, rufinamida y clobazam son los fármacos de elección de segunda línea aprobados por la Administración Federal de Alimentos y Drogas de los Estados Unidos. (FDA). El manejo quirúrgico incluye cirugía resectiva y callosotomía total o parcial. Otras alternativas son estimulación del Nervio Vago, dieta cetogénica, estimulación cerebral profunda y el uso médico de cannabis.

Lennox Gastaut syndrome is a catastrophic childhood-onset epileptic encephalopathy that presents a variety of electroclinical features: 1) Multiple seizure types, particularly tonic ones; 2) Cognitive impairment associated with behavioral disturbances; 3) Slow spike-wave complex on electroencephalographic (EEG) recordings, and generalized fast rhythms during sleep. The syndrome's etiology can be structural or genetic. Diagnosis at the time of clinical onset may be a challenge as not all criteria are met and there may not be a full picture; the differential diagnosis should consider childhood-onset myoclonic epilepsies. Treatment is equally complex as there are no clinically practical guidelines, reason for which experts' opinions must be sought. Initial treatment with valproic acid is suggested. Lamotrigine, felbamate, topiramate and clobazam are second line agents approved by the USA Food and Drug Administration (FDA). Surgical management may include resective surgery and/or corpus callosotomy (complete or partial). Other alternatives include Vagus Nerve Stimulation (VNS), ketogenic diet, Deep Brain Stimulation and Cannabis-based treatment.

Clinical effect of tonifying kidney and removing stasis decoction in the supplemental treatment of 80 cases with chronic nephritis / 中国基层医药

Objective To explore the clinical effect of tonifying kidney and removing stasis decoction combined with the traditional treatment in the treatment of 80 cases with chronic nephritis .Methods 80 patients with chronic nephritis were randomly divided into observation group and control group according to the digital table ,40 cases in each group.The control group was given conventional western medicine treatment ,the observation group was given tonifying kidney and removing stasis decoction on the basis of the control group .The clinical effect of the two groups was compared.Results Compared with before treatment [(0.9 ±0.3) points,(0.7 ±0.3) points,(0.9 ± 0.3)points,(0.8 ±0.2)points,(1.7 ±0.8)g,(1.7 ±0.9)mmol/L,(5.7 ±1.4)mmol/L,(106.8 ±24.5)μmol/L, (8.0 ±2.6)mmol/L;(0.9 ±0.3)points,(0.7 ±0.2)points,(0.9 ±0.3)points,(0.9 ±0.3)points,(1.6 ± 0.3)g,(1.8 ±0.4)mmol/L,(5.8 ±1.3)mmol/L,(107.2 ±20.1)μmol/L,(7.9 ±2.2)mmol/L],the scores of edema,sore throat,backache and the symptoms such as dizziness anaemic and 24 h urine protein,triglyceride,total cholesterol,uric creatinine and urea nitrogen levels after treatment [(0.2 ±0.2)points,(0.3 ±0.2)points,(0.3 ± 0.2)points,(0.2 ±0.2)points,(0.9 ±0.5)g,(1.4 ±0.5)mmol/L,(4.7 ±1.2)mmol/L,(91.2 ±19.8)μmol/L, (6.0 ±1.8)mmol/L;(0.5 ±0.2) points,(0.5 ±0.2) points,(0.6 ±0.2) points,(0.5 ±0.2) points,(0.7 ± 0.2)g,(0.9 ±0.3)mmol/L,(4.2 ±0.8)mmol/L,(79.5 ±11.7)μmol/L,(4.1 ±1.2)mmol/L] were significantly decreased,the differences were statistically significant (t=6.231,6.342,6.411,6.125,5.023,5.112,3.147,1.225, 2.014,all P<0.05).And the improvements of the observation group were statistically better than those of the control group (t=5.145,4.223,5.021,4.301,6.821,6.014,2.011,0.365,1.136,all P<0.05).Conclusion Tonifying kidney and removing stasis decoction in the supplemental treatment of chronic nephritis has high efficacy ,can remove blood stasis , activate blood and greatly alleviate the symptoms , so this method can be widely used in clinical treatment.

Treatment of Bilateral Tonic Pupil Associated with Syphilis

PURPOSE: We report a case of a male with bilateral tonic pupils associated with syphilis, that partially improved after syphilis treatment. CASE SUMMARY: A 27-year-old male presented with a 2-month history of near vision impairment. The right and left pupils were 5.5 mm and 6.5 mm in diameter, respectively, in the dark and 5.3 mm and 6.1 mm, respectively, in the light. Both pupils demonstrated light-near dissociation, slow constriction and redilation when looking at near, and constriction after instillation of 0.0625% pilocarpine. Serological tests were positive for syphilis, while cerebrospinal fluid testing was negative. Two months after treatment with intramuscular injection of benzathine penicillin G, his near vision subjectively improved and the right and left pupils were 5.9 mm and 6.4 mm, respectively, in the dark and 4.8 mm and 5.3 mm, respectively, in the light. The size of both pupils decreased and the pupillary light responses partially improved in both eyes. CONCLUSIONS: Patients with bilateral tonic pupils should have serological tests for syphilis. Recovery of tonic pupils can be expected after early treatment with effective antibiotics.