Febrile seizures: an overview

Febrile seizures are the most common seizure disorder seen in children and most often occur between the ages of 6 months and 5 years. Febrile seizures are usually self-limited and need no further neurodiagnostic evaluation. Rarely does medication need to be prescribed. For children with prolonged or multiple febrile seizures, diazepam rectal gel (Diastat) is a safe and effective treatment. There are no significant long-term risks associated with febrile seizures.     

Febrile seizures and epilepsy: the contributions of epidemiology

In the past, febrile seizures were considered to be a sign of epilepsy, a disorder characterised by recurrent unprovoked seizures. Currently, febrile seizures are considered to be a benign seizure syndrome that is distinct from epilepsy. This distinction has been possible largely because of the epidemiological evidence which is presented here in the form of a two-part argument. If febrile seizures are epilepsy one might expect that: (1) following a first febrile seizure, the risk of a second febrile seizure should be similar to the risk of an unprovoked seizure (in fact, the risk of a recurrent febrile seizure is approximately 34%, whereas the risk of an unprovoked seizure after having had a febrile seizure is approximately 2% to 3%); (2) the factors that predict recurrent febrile seizures should also predict subsequent unprovoked seizures. From the available literature, young age at the time of the first febrile seizure and a family history of febrile seizures predict recurrent febrile seizures, but do not predict subsequent unprovoked seizures. By contrast, a family history of epilepsy, complex febrile seizures and neurological abnormality are associated with an increased risk of subsequent epilepsy but are not consistently associated with the risk of a recurrent febrile seizure.     

Lacunar strokes: current concepts

Lacunar strokes result from occlusion of penetrating arteries in the deeper, subcortical parts of the cerebrum and brain stem. Approximately 19 percent of all strokes are of the lacunar variety with lacunar strokes representing the most common cerebrovascular complication of chronic hypertension. Four major clinical syndromes are pure motor hemiparesis, pure sensory stroke, ataxic hemiparesis, and the dysarthria-clumsy hand syndrome. The advent of computed tomography (CT) has allowed the antemortem study of lacunar disease and has shed new light on the pathogenesis and clinical course of lacunar strokes. Recently, it has been demonstrated that lacunar strokes may be embolic or hemorrhagic in causation, are not invariably associated with hypertension, and may be larger and associated with hypertension, and may be larger and associated with neurological manifestations that do not conform to the classic patterns. In most instances, however, recognition of the characteristic clinical presentation and confirmation of the diagnosis with noninvasive studies spare many patients unnecessary risks associated with anticoagulation, arteriography, or vascular surgery.     

Sarcoidosis: current concepts and case reports

Sarcoidosis is a systemic granulomatous disease of unknown etiology associated with various immune alterations and biochemical changes. This article reports recent advances in the conceptualization of the immune dysfunction with emphasis on helper T-cell overactivity in the lungs. Because 90 percent of patients with sarcoidosis have intrathoracic disease, the mode of presentation, radiographic findings, clinical course, and treatment of pulmonary involvement are discussed. Case reports are used to demonstrate the typical course of the disease and generally favorable outcome of the vast majority of patients seen in the non-referral setting. A rare case of neurosarcoidosis with neuroendocrine features is presented.     

Meconium aspiration syndrome: current concepts

Aspiration of meconium causes considerable perinatal morbidity and mortality. Meconium-stained amniotic fluid (MSAF) is present in 7-22% of all deliveries. Gastrointestinal secretions, bile, bile acids, mucus, pancreatic juice, cellular debris, amniotic fluid, swallowed vernix caseosa, lanuge, and blood comprise meconium. Passage of meconium occurs most often in deliveries after 42 weeks gestation (30%) because of high levels of the hormone motilin. This hormone is responsible for bowel peristalsis, defecation, and maturation of the innervation of the intestinal tract associated with vagal stimulation. It tends to be a marker of pre/intrapartum asphyxia. MSAF is also a sign of fetal hypoxia or acidosis. It appears that meconium aspiration is predominantly an intrauterine event. The definition of meconium aspiration syndrome (MAS) is respiratory distress in a meconium-stained newborn, compatible radiographic findings (e.g., coarse, irregular pattern of increased density throughout the lung), and symptoms that can not otherwise be explained. MAS occurs in 1-4% of infants with MSAF and up to 10% of those with thick meconium. Mortality ranges from 6% to 40%. Initially, meconium particles mechanically obstruct the small airways. Later, chemical pneumonitis and interstitial edema are responsible for small airway obstruction. As many as 66% of persistent pulmonary hypertension of the newborn cases are associated with MAS. Clinical signs and symptoms of MAS include frothy, yellow-green secretions from the mouth; very rapid breathing; intercostal retractions; cyanosis; overinflated chest due to air trapping; rales; and rattling in the throat. Transcervical amnio-infusion of warmed normal saline may be an obstetric intervention in cases of MSAF. Intrapartum oropharyngeal suctioning and postpartum intratracheal suctioning has reduced the incidence of MAS. Routine care of MAS infants includes monitoring and correcting of the thermal environment and blood glucose and calcium levels. Chest physiotherapy, saline lavage, management of hypoxemia, surfactant therapy, and systemic steroid treatment are MAS therapies.     

International health: various current concepts

This study is a theoretical approach on international health with the purpose to point out some aspects which can enhance the understanding of the International Health field and its operational and conceptual elements in the socio-economic process of integration of neighboring countries.     

Glucose control guidelines: current concepts

The Diabetes Control and Complications Trial (DCCT) ended decades of controversy regarding the necessity of tight glycemic control for type 1 diabetes by demonstrating that glucose control using intensive insulin therapy significantly reduced long-term microvascular complications. The American Diabetes Association (ADA) guidelines empirically support the same goal of attempting to obtain normoglycemia in patients with type 2 disease; however, unlike in type 1 disease, insulin is a tertiary option, following diet, exercise, and oral agents. Emerging long-term intervention data in type 2 diabetes suggest that insulin may pose increased cardiovascular risk in this already 'at-risk' population. However, many type 2 diabetics will eventually require insulin. Clearly, more studies are warranted to assess the risks, benefits, and feasibility of improved glycemic control in type 2 diabetes. Nonetheless, two principles are clear. First, promoting blood glucose levels approaching normoglycemia is an important factor in preventing long-term microvascular complications. Second, type 2 diabetes comprises numerous metabolic conditions; therefore an integrated effort by the patient and healthcare team is required to optimize blood glucose and serum lipid levels and minimize cardiovascular risk factors.     

Prader-Willi syndrome: clinical picture, psychosocial support and current management

AIM: Prader-Willi syndrome (PWS) is a rare, genetically based disorder that occurs in about 1 of 15 000 live-born children. To raise a child with PWS is challenging for parents and requires support from multiprofessional habilitation services. This paper maps the need for psychosocial support and current management of children and adolescents with PWS. METHOD: Parents to 58 children with PWS (aged 5-18 years) completed questionnaires covering clinical, diagnostic and psychosocial issues. RESULTS: The children received their diagnosis at a mean age of 2.5 year. Growth hormone treatment was given to 72%. Sixty-three per cent of the sample was not overweight. Neuropsychiatric symptoms were common from early age and some were related to obesity. Most parents wanted information as to availability of external resources and future child needs. Few parents needed family-directed support. CONCLUSION: The overall impression is that the eating disorder is managed relatively well. Even so PWS symptoms typically exacerbate over time and consequently parents need continuous support throughout childhood and adolescence. Greater attention should be paid to idiosyncrasies in cognitive functioning and to clinical markers of neuropsychiatric problems.     

Capitation in dentistry: original concepts and current reality

Modern dental capitation was conceived as being based on staff model group practice, receiving regular periodic payments to provide comprehensive care with few exclusions, limitations and copayments, to a given population. High utilization, completion and recall rates were expected. Examples are presented. The dominant form of capitation has become a network of solo and small group practices, usually with a for-profit intermediary. Premiums are low and administrative costs are high. There are many exclusions and limitations. Low utilization and under-treatment are endemic. Specific examples are presented. The reasons for this development include competition among dentists concerned about busyness, and predominance of cost control concerns over quality concerns on the part of purchasers.     

Febrile seizures following measles and varicella vaccines in young children in Australia

BackgroundFebrile seizures (FS) are common in childhood with incidence peaking in the second year of life when measles and varicella-containing vaccines are administered. This study aimed to examine the vaccine-attributable risk of FS following separate administration of MMR and monovalent varicella vaccines (VV) prior to a planned change to MMRV as the second dose of measles-containing vaccine at 18 months of age.MethodsAll FS cases in children aged <5 years from 1st January 2012 to 30th April 2013 were identified from emergency department (ED) and inpatient databases at five Australian tertiary paediatric hospitals participating in PAEDS (Paediatric Active Enhanced Disease Surveillance). Immunization records were obtained from the Australian Childhood Immunization Register (ACIR). The relative incidence (RI) of FS following MMR dose 1 (MMR1) and VV in children aged 11–23 months was determined using the self-controlled case series (SCCS) method and used to calculate attributable risk.ResultsThere were 2013 FS episodes in 1761 children. The peak age at FS was 18 months. The risk of FS was significantly increased 5–12 days post receipt of MMR1 at 12 months (RI = 1.9 [95% CI: 1.3–2.9]), but not after VV at 18 months (RI = 0.6 [95% CI: 0.3–1.2]. The estimated excess annual number of FS post MMR1 was 24 per 100,000 vaccinated children aged 11–23 months (95% CI = 7–49 cases per 100,000) or 1 per 4167 doses.ConclusionsOur study detected the expected increased FS risk post MMR1 vaccine at 12 months, but monovalent varicella vaccine at age 18 months was not associated with increased risk of FS. This provides baseline data to assess the risk of FS post MMRV, introduced in Australia as the second dose of measles-containing vaccine at 18 months of age in July 2013.     

Inferior vena cava filter thrombosis: a review of current concepts, evidence, and approach to management

The increased risk of venous thrombosis within and below the inferior vena cava (IVC) is the main long-term complication of IVC filter placement. In this article, we discuss current concepts regarding the incidence, risks, and management of IVC filter thrombosis. Evidence of the association of each of the following factors is reviewed: type and design of the filter device, population demographics, underlying hypercoagulable states/anticoagulation, modality used to assess for thrombosis, and length of time elapsed since filter placement. Certain double-basket filter designs and a hypercoagulable state are associated with increased incidence of IVC filter thrombosis. Most cases of IVC filter thrombosis are asymptomatic. While large series data on the use of magnetic resonance imaging for the detection of filter thrombosis remain unavailable, evidence suggests that contrast-enhanced computed tomography is preferable to Doppler sonography. A proposed algorithm for the management of IVC filter thrombosis is provided.