Non-Pharmacologic Management of Epilepsy

Non pharmacological treatment, in addition to pharmacological treatment is indicated in patients with refractory/pharmacoresistant epilepsy and includes ketogenic diet, deep brain stimulator, vagal nerve stimulator, transcranial magnetic stimulation and epilepsy surgery. Ketogenic diet has been recommended since 1921 and has been proved to be a safe and effective treatment for intractable epilepsy. Deep brain stimulator, has been used in the treatment of movement disorders for many years and recently been tried in the treatment of pharmacoresistant epilepsy. Vagus nerve stimulator is increasingly being used as an effective seizure aborting technique in patients not responding to anticonvulsants. Transcranial magnetic stimulation is a noninvasive brain stimulation technique which is being increasingly researched for use in patients with medication-refractory seizures who are not suitable candidates for surgery. Evolution of epilepsy surgery including Vagal nerve stimulator and Deep brain stimulator, as a successful treatment modality for intractable epilepsy has been influenced over the last decade by substantial advancement in imaging and operative/device related technology. The current article reviews the indications, mechanism of action, technological aspects and efficacy of the aforementioned modalities in the treatment of intractable/pharmacoresistant epilepsy in pediatric age group.     

Antiparasitic efficacy of piperine against Argulus spp. on Carassius auratus (Linn. 1758): in vitro and in vivo study

Argulus are common aquatic ectoparasites that create one of the major threats to aquaculture due to absence of suitable therapy. Piperine, a bioactive component of Piper longum, has medicinal properties and acts as anti-inflammatory, antibacterial, and antifungal, considering eco-friendliness and cost-effectiveness. The present study aimed to evaluate antiparasitic effect of piperine against an ectoparasite Argulus spp. on Carassius auratus. Artificial Argulus infection was carried out by cohabitation method, and the fishes were selected for in vivo study when intensity of Argulus infestation was observed to be 15–20 Argulus per fish. In vitro and in vivo studies were performed at different concentration 1.0 (T ₁), 3.0 (T ₂), 5.0 (T ₃), 7.0 (T ₄), and 9.0?mg?l^?1 (T ₅) of piperine solution to treat Argulus for 3 and 72?h, respectively. The acute toxicity test for piperine EC 97?% against goldfish was performed for 96?h. The 96?h median lethal concentration (LC₅₀) for piperine was found to be 52.64?mg?l^?1. In vitro effect of piperine solution led to 100?% mortality of Argulus at 9.0?mg?l^?1 in 3?h whereas, under in vivo test, the 100?% antiparasitic efficacy of piperine solution was found at 9.0?mg?l^?1 in 48?h. The EC₅₀ for 48?h was 9.0?mg?l^?1, and thus, therapeutic index is 5.8. The results revealed that piperine at a concentration of 9.0?mg?l^?1 can be used as a potential natural agent for controlling Argulus parasite.     

The effect of oral administration of Allium sativum extracts on lead nitrate induced toxicity in male mice

Lead is a common environmental occupational toxic metal, known to have indirect oxidative effects. Considering the antioxidant properties of garlic, this study was undertaken to evaluate the therapeutic efficacy of garlic extracts in terms of normalization of altered hematological, biochemical and immunological parameters, and depletion of inorganic lead burden in blood, kidney and brain tissues. Chronic lead nitrate ingestion showed a significant decline in total erythrocyte count, total leukocyte count, hemoglobin concentration, lymphocyte and monocyte content, while neutrophil content increased in lead nitrate treated group. Pb(NO₃)₂ exposure elicited a significant escalation in thiobarbituric acid reactive substances level and depletion in reduced glutathione content and antioxidant enzymes namely, superoxide dismutase and catalase in kidney and brain. Activities of aspartate transaminase, alanine transaminase, acid phosphatase and alkaline phosphatase augmented significantly in kidney and brain of lead exposed mice. Lead nitrate treatment decreased protein content while cholesterol and lead burden increased significantly. A decrease in viability of macrophage, phagocytic index, immunoglobulin level and plaque count were the salient features observed in lead exposed animals. However, oral administration of garlic extracts to Pb(NO₃)₂ treated groups attenuated the deranged parameters to some extent. This indicates that garlic can be a protective regimen for lead toxicity.     

Evaluation of intracoronary blood from obstructive vessel in patients of ST-elevation myocardial infarction undergoing PPCI

ObjectiveInformation available on acid–base imbalance in ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention is limited and no data were present on intracoronary blood analysis, extracted from obstructed artery.MethodsThis was a prospective study conducted over 12 months in which STEMI patients presenting in emergency and undergoing primary percutaneous coronary intervention were included. Blood gas analysis of intracoronary arterial blood from obstructed vessel and peripheral arterial blood was performed. Patients in whom adequate intracoronary sample could not be obtained were excluded. Intracoronary and peripheral arterial blood gas measurements were correlated and relationship of intracoronary parameters were compared with clinical parameters, investigational markers and short-term outcome.ResultsThe mean age of study population was 54.8 years and average symptom onset to door time was 162 min. On comparing intracoronary blood with peripheral blood arterial obtained, pH (95% confidence interval [CI] ?0.01 to 0.02;p = 0.44), lactate (95% CI 0.03–0.1;p = 0.28), bicarbonate (95% CI 0.6–1.5;p = 0.64), pCO₂ (95% CI 1.1–2.4;p = 0.79) and pO₂ (95% CI 3.2–47.5; p = 0.06) were all found to be statistically insignificant. Intracoronary hyperlactatemia was present in patients presenting with higher symptom onset to door time (p = 0.025). Systolic blood pressure (SBP) (p = 0.03) was also significantly lower in patients who had high intracoronary lactate levels.ConclusionThe evaluation of intracoronary blood provides no additional information regarding the prognosis and short-term (30-day) outcome of the patients when compared with peripheral blood. However, there was a significant intracoronary hyperlactatemia in patients presenting late after symptom onset. SBP was also significantly less in patients with high intracoronary lactate, which signifies that predominant cause of hyperlactatemia was systemic hypoperfusion rather than local increase in lactate levels.     

A quantitative relationship of electrocardiographic criteria of left ventricular hypertrophy with echocardiographic left ventricular mass: a multivariate approach

The purpose of this study was to evaluate the sensitivity of various electrocardiographic (EKG) criteria of left ventricular hypertrophy (LVH) in relation to echocardiographic left ventricular mass (LVME) and to assess the relative strength of various EKG variables used in the diagnosis of LVH by multivariate analysis. An attempt was also made to determine if a new combination of precordial and T-wave voltage could improve the sensitivity of EKG. In 89 patients, M-mode echocardiograms and standard EKGs were studied. Correlation of Romhilt-Estes point-score system with LVME was r = 0.621, sensitivity and specificity was 57 and 81%, respectively. Other voltage criteria had lower sensitivity. Various combinations of precordial and T-wave voltage were not superior. The quantitative relationship of individual EKG variable, QRS duration, S V1-3, R V4-6, strain T wave, left atrial abnormality, intrinsicoid deflection and axis, with LVM was, r = 0.661, 0.595, 0.429, 0.42, 0.347, and 0.225, respectively. By multivariate analysis, QRS duration, S V1-3, T-wave and R V4-6 voltage had F-value (relative strength) of 27.95, 27.15, 22.02, and 4.03, respectively, other variables were statistically insignificant. In conclusion, the most important EKG variables predictive of LVH are QRS duration, S V1-3, strain T-wave and lateral voltage in decreasing value. Rescoring these variables in accordance to their correlation to LVM may improve EKG sensitivity for the diagnosis of LVH.     

Strain‐Specific Impact of Fusobacterium nucleatum on Neutrophil Function

Background: Neutrophil function is critical for initiation and progression of infecto‐inflammatory diseases. Key quorum‐sensing plaque bacteria, such as Fusobacterium nucleatum, act as bridging species between early and late colonizer pathogens, such as Porphyromonas gingivalis, as the biofilm ages and periodontal inflammation increases. This study is designed to determine impact of different F. nucleatum strains on neutrophil function. Methods: Cells of human promyelocytic leukemia cell line‐60 were differentiated into neutrophil‐like cells and cultured with F. nucleatum strains of subspecies (ssp.) nucleatum ATCC 25586, ssp. polymorphum ATCC 10953, and ssp. vincentii ATCC 49256. Neutrophil phagocytosis of F. nucleatum strains and neutrophil apoptosis were analyzed by flow cytometry. Superoxide generation was measured by cytochrome C reduction in the presence and absence of N‐formyl‐L‐methionyl‐L‐leucyl‐L‐phenylalanine (fMLP) (1 μM) stimulation. Proinflammatory cytokine release was determined after 2, 6, and 24 hours of culture in the presence/absence of different F. nucleatum strains. Expression of Toll‐like receptor (TLR)2, TLR4, and nuclear factor (NF)‐kappa B mRNA levels were analyzed using real‐time quantitative polymerase chain reaction. Each experiment was repeated at least three times in triplicate. Data were analyzed using analysis of variance followed by post hoc Bonferroni correction. Results: All strains of F. nucleatum significantly increased phagocytic capacity of neutrophils. Neutrophil phagocytosis of F. nucleatum ssp. polymorphum was significantly greater than that of F. nucleatum ssp. vincentii and ssp. nucleatum (P <0.001). F. nucleatum ssp. nucleatum and ssp. polymorphum significantly blocked fMLP‐induced superoxide generation (P <0.001). Although F. nucleatum vincentii also reduced superoxide generation (25%), the impact was not as strong as that of ssp. nucleatum (83%) and ssp. polymorphum (100%). All F. nucleatum strains stimulated significant increase in neutrophil apoptosis compared with control (P <0.001) and significantly increased expression of NF‐κB mRNA in neutrophils (P <0.05). Levels of interleukin‐8 and tumor necrosis factor‐α produced by neutrophils were significantly increased in all F. nucleatum groups compared with control (P <0.001). Conclusions: These findings suggest that different strains of F. nucleatum impact neutrophil function in different ways. Two of three subspecies blocked neutrophil superoxide generation in response to a secondary stimulus, preventing oxidative killing by neutrophils. The direct role of bridging species in pathogenesis of periodontitis may be greater than previously suspected in which they create a favorable environment for pathogenic transition of the dental ecosystem.     

MR venography using time-resolved imaging in interventional management of pelvic venous insufficiency

Purpose of Review

To evaluate the utility of magnetic resonance venography with time-resolved imaging (MRV TRI) in the diagnosis of pelvic vein insufficiency (PVI).

Recent Findings

A retrospective single-center review of N = 17 consecutive patients who underwent pelvic MRI for the assessment of PVI was performed. N = 8/17 (47%) studies were positive for PVI. TRI imaging demonstrated N = 6/8 patients with Grade 0–3 PVI and N = 2/8 patients with May–Thurner Syndrome. N = 4/8 patients underwent elective endovascular management, all of which were technically successful.

Summary

In the assessment of PVI, MRV TRI provides a dynamic assessment of venous insufficiency, serving as an adjunct to the imaging diagnosis of this pathology.

     

Drink more, and eat less: advice in obstructive hypertrophic cardiomyopathy

This report describes a series of symptomatic patients with obstructive hypertrophic cardiomyopathy with significant postprandial hemodynamic changes. This finding was identified by history, clinical examination, and echocardiography in 6 consecutive symptomatic patients referred for the evaluation of ventricular septal reduction therapy. Counseling these patients with dietary changes to include small frequent meals and to increase noncaffeinated fluid intake resulted in reductions in symptoms. In conclusion, severe symptoms in obstructive hypertrophic cardiomyopathy unresponsive to pharmacologic treatment frequently result in referral for definitive septal reduction therapy through surgery or, less frequently, alcohol septal ablation therapy. However, recognition of postprandial exacerbation in symptomatic patients may allow for nonpharmacologic dietary interventions that may obviate the need for more invasive therapies and their associated complications.