Responsive neurostimulation as a treatment for super-refractory focal status epilepticus: a systematic review and case series.

OBJECTIVE: Super-refractory status epilepticus (SRSE) has high rates of morbidity and mortality. Few published studies have investigated neurostimulation treatment options in the setting of SRSE. This systematic literature review and series of 10 cases investigated the safety and efficacy of implanting and activating the responsive neurostimulation (RNS) system acutely during SRSE and discusses the rationale for lead placement and selection of stimulation parameters. METHODS: Through a literature search (of databases and American Epilepsy Society abstracts that were last searched on March 1, 2023) and direct contact with the manufacturer of the RNS system, 10 total cases were identified that utilized RNS acutely during SE (9 SRSE cases and 1 case of refractory SE [RSE]). Nine centers obtained IRB approval for retrospective chart review and completed data collection forms. A tenth case had published data from a case report that were referenced in this study. Data from the collection forms and the published case report were compiled in Excel. RESULTS: All 10 cases presented with focal SE: 9 with SRSE and 1 with RSE. Etiology varied from known lesion (focal cortical dysplasia in 7 cases and recurrent meningioma in 1) to unknown (2 cases, with 1 presenting with new-onset refractory focal SE [NORSE]). Seven of 10 cases exited SRSE after RNS placement and activation, with a time frame ranging from 1 to 27 days. Two patients died of complications due to ongoing SRSE. Another patient's SE never resolved but was subclinical. One of 10 cases had a device-related significant adverse event (trace hemorrhage), which did not require intervention. There was 1 reported recurrence of SE after discharge among the cases in which SRSE resolved up to the defined endpoint. CONCLUSIONS: This case series offers preliminary evidence that RNS is a safe and potentially effective treatment option for SRSE in patients with 1-2 well-defined seizure-onset zone(s) who meet the eligibility criteria for RNS. The unique features of RNS offer multiple benefits in the SRSE setting, including real-time electrocorticography to supplement scalp EEG for monitoring SRSE progress and response to treatment, as well as numerous stimulation options. Further research is indicated to investigate the optimal stimulation settings in this unique clinical scenario.

Evaluation of advanced practice provider related return visits to a pediatric emergency department and their outcomes.

BACKGROUND: While multiple studies have evaluated physician-related return visits (RVs) to a pediatric emergency department (PED) limited data exists for Advanced Practice Provider (APP)-related RVs, hence our study aimed to evaluate APP-related RVs and their outcomes in a PED. METHODS: We conducted a retrospective review of 72-h RVs where clinical care was independently provided by an APP during the index visit from January 2018 to December 2019. We extracted patient demographics, index and return visits' characteristics and outcomes. Reasons for RVs were categorized as progression of illness, medication-related, callbacks and others. Index visits were assessed for any diagnostic errors; impact of which to the patient was classified as none, minor or major. RESULTS: Our APP-related RV rate was 2.1% (653/30,328). 462 eligible RVs were included in the final analysis. Majority of RVs were for medical reasons (n = 442, 95.7%); lower acuity (Emergency Severity Index ≥3, n = 426, 92.2%); due to persistence/progression of illness (n = 403; 87.2%) with viral illness being the common diagnosis (n = 159; 34.4%). 12 (2.6%) RVs were secondary to callbacks (8 radiology callbacks; 4 false positive blood cultures). Diagnostic errors were noted in 14 (3%) encounters of which 3 resulted in a major impact; radiological (7 fractures) and ophthalmological (2 corneal abrasions and 2 foreign bodies) misses constituted the majority of these. CONCLUSIONS: APP-related RVs for low acuity medical patients remain low and are associated with good outcomes. Diagnostic errors account for a minority of these RVs. Focused interventions targeting provider errors can further decrease these RVs.

Thrombosis of external iliac and common femoral arteries secondary to blunt trauma due to handlebar injury.

BACKGROUND: Vascular injuries are uncommon following a bicycle handlebar injury in children. However, they are associated with an extremely high morbidity including limb loss and asymmetric limb growth. CASE PRESENTATION: 11 year old previously healthy female who presented to a pediatric emergency department immediately after sustaining blunt trauma to her abdomen by a bicycle handlebar. She complained of pain in her right lower extremity without paresthesia and was noted to have a painful superficial laceration to the right lower abdomen with tenderness on palpation. The extremity was noted to be mottled, cool to touch, with decreased sensations and delayed capillary refill but intact motor function. The peripheral pulses in the extremity were noted to be absent on exam, which was confirmed by a bedside Doppler. A Computed Tomography Angiography (CTA) of the abdomen and pelvis revealed an occluding thrombus in the external iliac and right common femoral arteries which required surgical repair. She subsequently developed occlusion secondary to traumatic dissection and compartment syndrome in the same extremity requiring repeat surgical intervention. CONCLUSION: In managing patients with blunt force trauma to the abdomen from handlebars, clinicians should have a high index of suspicion for vascular injuries even with low-risk mechanism of injury and superficial injuries noted on exam. Their assessment should include immediate examination of bilateral peripheral pulses of the lower extremities to evaluate for clinical findings associated with acute lower limb ischemia as well as bedside Doppler exams and early consideration of CTA to assess for occult vascular injury.

Assessment of Cardiac Function in Fetuses of Gestational Diabetic Mothers During the Second Trimester.

Fetuses of diabetic mothers may have structural or functional cardiac abnormalities which increase morbidity and mortality. Isolated functional abnormalities have been identified in the third trimester. The aim of the present study was to assess fetal cardiac function (systolic, diastolic, and global myocardial performance) in the second trimester in mothers with gestational diabetes, and also to relate cardiac function with glycemic control. Mothers with gestational diabetes mellitus referred for fetal cardiac evaluation in the second trimester (between 19 and 24 weeks) from March 2015 to February 2016 were enrolled as case subjects in this study. Non-diabetic mothers who had a fetal echocardiogram done between 19 and 24 weeks for other indications were enrolled as controls. Functional cardiac variables showed a statistically significant difference in isovolumetric relaxation and contraction times and the myocardial performance index and mitral E/A ratios in the gestational diabetic group (p = 0.003). Mitral annular plane systolic excursion was significantly less in the diabetic group (p = 0.01). The only functional cardiac variable found abnormal in mothers with poor glycemic control was the prolonged isovolumetric relaxation time. Functional cardiac abnormalities can be detected in the second trimester in fetuses of gestational diabetic mothers and timely intervention can improve postnatal outcomes.

Human papilloma virus and oral lesions in gutka eating subjects in Karachi.

OBJECTIVE: To determine the frequency of HPV in eaters of Gutka (betel, areca, lime and tobacco concoction), presenting with oral lesions. STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Ziauddin University Research Laboratory, from February to July 2010. METHODOLOGY: Subjects munching Gutka fulfilled the inclusion criteria. Samples were collected in the form of 20 - 40 ml oral rinse from 262 subjects who were habitual eaters of Gutka after an informed consent. Gentle brushings from the lesion were taken from subjects with the help of a brush at the other end of dental floss and the oral rinse was stored at 4°C until DNA extraction. DNA was extracted and PCR was performed using HPV consensus primers Gp5+/Gp6+. Oral cavity was examined for the presence of ulcer, trismus, sub-mucosal fibrosis, leukoplakia and/or warts. RESULTS: Out of 262 subjects, 42 were females and 220 males with an average age of 27± 10 years. HPV was positive in 47 subjects (17.9%). HPV frequency was 2.7% greater in chewers with more than 10 years of habit compared to less than 10 years. Examination of oral cavity showed 78% presenting with more than one complaint including oral ulcers (25%), rough mucosa (62%), sub-mucosal fibrosis (24%), leukoplakia (20%) and erythroplakia (10.6%). Highest frequency of HPV was observed in erythroplakia (25%). Association between presence of symptoms and HPV shows an ODDS RATIO: ad/bc= 4982/430=11.6. CONCLUSION: Oral lesions caused by constant exposure to Gutka are associated with high frequency of HPV infection, which may be a risk factor for squamous cell carcinoma of the oral cavity. People should be educated about the consequences of Gutka abuse.