Levetiracetam for the treatment of neonatal seizures.

Seizures are a common occurrence in the neonatal intensive care unit, especially among low-birth-weight infants. The efficacy and safety of standard anticonvulsants have not been evaluated extensively in the neonate. In addition, there is concern for the adverse effects of phenobarbital on long-term development. Levetiracetam has been a commonly prescribed oral anticonvulsant for the use of adjunctive therapy for partial seizures in adults with favorable tolerability, and it has been recently approved for children older than age 4 years. There are no published studies regarding the safety and efficacy of this medication in the infant population. This report describes the initiation of levetiracetam in 3 infants, aged 2 days to 3 months, for refractory seizures or intolerance to other anticonvulsants. Each patient was without seizure on levetiracetam monotherapy, and there were no adverse effects.

Successful treatment of recalcitrant restless legs syndrome with botulinum toxin type-A.

STUDY OBJECTIVE: We report the effective use of injected BTX-A to treat refractory restless legs syndrome (RLS). METHODS: This is an observational case series of 3 patients meeting the essential diagnostic criteria for RLS whose symptoms were refractory to or who refused oral medication. Areas of maximal discomfort were injected as described below. RESULTS: Patient #1, a 58-year-old man with refractory RLS, received injections in both legs. The effect persisted for 12 weeks after injections. He temporarily stopped taking gabapentin. He experienced a mild increase in a timed run. Patient #2, a 38-year-old man with refractory RLS, received BTX-A injections in both legs and his lumbar paraspinal muscles. Three days after injection, he reported great improvement. Within 1 month, his Epworth Sleepiness Scale score had decreased from 19 to 5. He stopped oral therapy during the peak therapeutic period. There were no untoward effects. Patient #3, a 38-year-old woman had a prolonged sleep latency due to RLS. BTX-A was administered in the legs. In 2 days, her discomfort and her subjective sleep latency improved. Both the urge to move and nocturnal restlessness resolved for 10 weeks. There were no untoward effects in all patients, and the response was repeated in successive injection cycles. CONCLUSIONS: Intramuscular BTX-A alleviated symptoms, reduced medication use, and/or reduced daytime sleepiness with minimal, if any, untoward effects. BTX-A should be further investigated in controlled studies as a treatment of RLS.

Rash, fever, and neck pain in the office: is this a neurologic emergency?

Anticonvulsants, neuroleptics, and antispasticity agents are used with increasing frequency in the pediatric population. Each of the drugs discussed in this article has serious but potentially reversible adverse effects. Pediatric primary care providers must be aware of the potential emergencies associated with the use of these neurologic medications to provide prompt and effective treatment.

Neurodevelopmental toxicology.

The fields of neurotoxicology and developmental toxicology are exploding in research and interest. Much of the data currently known are from epidemiologic human studies or studies of animal models. Each of these modes is difficult to translate to individual clinical encounters. It is often difficult to state with certainty which of the numerous chemical or physical agents in our environment are neurotoxic. Basic scientists will help with advances in molecular biology and toxicology. Improved clinical understanding of these issues may help patients to understand the medical issues; allay feelings of anxiety, guilt, or fear; and avoid unnecessary testing. For exposures that manifest as threshold phenomena, such as lead, the risk to society is even greater than to an individual. Individual risk may be less of a concern than the population's risk because small elevations in the average BLL can cause profound shifts in the normative curve of intelligence, increasing the burden on our institutions and bankrupting the brain trust. Good scholarship and interpersonal judgement are vital when counseling patients on the potential consequences of chemical exposures and are no less important when making policy. The challenge for the clinician reading the research is to remain aware of the limitations and biases of our science.

Nerve agent attacks on children: diagnosis and management.

Nerve agents (NAs) are the most lethal chemical weapons. We review the pathophysiology and management of NA poisoning of children. NAs cause cholinergic crisis. Children may manifest signs of cholinergic poisoning differently than adults. Children may be less likely to manifest miosis and glandular secretions. They may present with neurologic derangements alone. The goals of treatment should be to limit additional exposure, to provide respiratory support, and to prevent neurologic morbidity. Autoinjectors are optimal delivery vehicles for intramuscular antidotes and are likely to be used in civilian prehospital care. Antidotes include anticholinergics, oximes, and benzodiazepines. Several medications may be available within each class of antidotes. Clinicians will select an antidote based on the status of the individual victim, the accessibility of supportive care, and the availability of the drug. Atropine is well-tolerated and high doses may be required. The oxime pralidoxime chloride has a longer half-life in children. Currently, diazepam is the standard NA anticonvulsant. Midazolam may be the most effective intramuscular anticonvulsant after NA exposure, but, despite its efficacy, it is not an approved agent for seizures. Supportive care and long-term complications are summarized.