Resolution of epileptic encephalopathy following treatment with transdermal nicotine

We report resolution of an epileptic encephalopathy by administration of transdermal nicotine patches in an adolescent with severe nonlesional refractory frontal lobe epilepsy. The 18.5‐year‐old female patient had refractory epilepsy from the age of 11. Recurrent electroencephalography (EEG) recordings showed mostly generalized activity, albeit with right frontal predominance. Almost all antiepileptic medications failed to provide benefit. She developed an encephalopathic state with cognitive decline. The nonlesional frontal lobe epilepsy and a family history of a cousin with nocturnal epilepsy with frontal origin suggested genetic etiology. Transdermal nicotine patches brought complete resolution of the seizures, normalization of the EEG, and a significant improvement in her thinking process and speech organization. Sequencing of the CHRNB2 and CHRNA4 genes did not detect a mutation. Transdermal nicotine patches should be considered in severe pharmacoresistant frontal lobe epilepsy.     

Comparative dynamics of four smoking withdrawal symptom scales

Aims To examine the association of person‐specific trajectories of withdrawal symptoms of urge‐to‐smoke, negative affect, physical symptoms and hunger during the first 7 days after smoking cessation with abstinence at end of treatment (EOT) and at 6 months. Design Hierarchical linear modeling (HLM) was used to model person‐specific trajectory parameters (level, slope, curvature and volatility) for withdrawal symptoms. Setting University‐based smoking cessation trials. Participants Treatment‐seeking smokers in clinical trials of transdermal nicotine versus nicotine spray (n = 514) and bupropion versus placebo (n = 421). Measurements Self‐reported withdrawal symptoms for 7 days after the planned quit date, and 7‐day point prevalence and continuous abstinence at EOT and 6 months. Findings In regressions that included trajectory parameters for one group of withdrawal symptoms, both urge‐to‐smoke and negative affect were predictive of abstinence while physical symptoms and hunger were generally not predictive. In stepwise regressions that included the complete set of trajectory parameters across withdrawal symptoms (for urge‐to‐smoke, negative affect, physical symptoms and hunger), with a single exception only the trajectory parameters for urge‐to‐smoke were predictive. Area under the receiver operator characteristic curve was 0.594 for covariates alone, and 0.670 for covariates plus urge‐to‐smoke trajectory parameters. Conclusions Among a number of different withdrawal symptoms (urge‐to‐smoke, negative affect, physical symptoms and hunger) urge‐to‐smoke trajectory parameters (level, slope and volatility) over the first 7 days of smoking cessation show the strongest prediction of both short‐ and long‐term relapse. Other withdrawal symptoms increase the predictive ability by negligible amounts.     

Electrocardiographic left ventricular hypertrophy predicts arrhythmia and mortality in patients with ischemic cardiomyopathy

Purpose

The relatively low incidence of device-treated ventricular arrhythmias in patients with ischemic cardiomyopathy (ICM) who receive implantable cardioverter defibrillators (ICDs) for primary prevention makes improved risk stratification of ICM patients a priority. Although Cornell product (CP) ECG left ventricular hypertrophy (LVH) has been associated with increased mortality in hypertensive patients and population-based studies, whether CP LVH can improve risk stratification of high-risk ICM patients is unclear. The aim of this study is to examine if electrocardiographic LVH predicts mortality and incident ventricular arrhythmia in patients with ICM.

Methods

All-cause mortality was examined in 317 patients with ICM and a history of non-sustained ventricular tachycardia (VT) who underwent electrophysiology testing. Incident VT and ventricular fibrillation (VF) were assessed in ICD recipients (n?=?186). ECG LVH was defined by CP criteria: [(R _aVL?+?S _V3)?+?6?mm in women]?×?QRS duration >2,440?mm?ms.

Results

During 3?years of follow-up, mortality was 20% (64 of 317) and death or incident VT or VF occurred in 35% of ICD recipients. CP LVH was associated with significantly greater 3-year mortality (28% vs 15%, p?=?0.015) and 3-year mortality or incident VT/VF in ICD patients (48% vs 35%, p?=?0.011). In Cox multivariate models, CP LVH was an independent predictor of mortality in all patients (hazard ratio (HR) 1.81, 95% confidence interval (CI) 1.11?C2.97, p?=?0.020) and of the composite endpoint of mortality or incident ventricular arrhythmia in ICD patients (HR 1.82, 95% CI 1.12?C3.00, p?=?0.016).

Conclusions

ECG LVH using CP criteria may enhance risk stratification in high-risk patients with ICM.     

Management of Sphincter Dyssynergia Using the Sphincter Stent Prosthesis in Chronically Catheterized SCI Men

Abstract

This effort represents a subset analysis of the long-term Multicenter North American Trial of the UroLume sphincter stent prosthesis to determine the effect of the sphincter stent prosthesis in SCI men afflicted with detrusor-external sphincter dyssynergia (DESD) and chronically managed with an indwelling urinary catheter. Forty-one of 153 male patients in this study were evaluated urodynamically before and after placement of the sphincter stent prosthesis. Of the 41 patients, 34 (81 percent) suffered cervical-level injury while 10 patients (25 percent) had been treated previously with external sphincterotomy. Forty patients (98 percent) were troubled with recurrent urinary tract infections (UTI), with a mean of 4.6±3 episodes of UTI per year. Seven patients (17 percent) demonstrated hydronephrosis prior to stent placement.

Follow-up ranged from six to 44 months. Voiding pressures decreased from a mean of 77±23 cmH20 preoperatively to 35±18 cmH20 at 12 months (n=34) and 33±20 cmH2Û at 24 months (n=22) after stent insertion (p=0.001). Post-void residual urinary volume decreased from 202±187 ml preinsertion to 64±69 ml at 24 months (p=0.001) postinsertion. Maximum cystometric capacity remained constant at 201 ±144 ml preinsertion to 203±79 ml at 24 months (p=0.75) postinsertion. No significant changes in any of the urodynamic parameters occurred after 24 months of follow-up between patients with (n=10) and without (n=31) previous external sphincterotomy.

Neither hemorrhage requiring blood transfusion, obstructive hyperplastic epithelial overgrowth, stent encrustation or stone formation, nor soft tissue erosion occurred in any patient. No deleterious effects were observed on erectile function. Hydronephrosis resolved in four, and improved in three, of seven patients with hydronephrosis preoperatively. Eighty-two percent of the patients demonstrated complete stent epithelialization after six months, while 96 percent were epithelialized two years after stent insertion. In three patients, stent migration required repositioning or removal within the first month. In another two patients, the stent prostheses were removed one year postinsertion because of problems with condom catheter drainage.

The sphincter stent prosthesis is an attractive, potentially reversible treatment option for DESD in men managed with an indwelling catheter, even if external sphincterotomy has been performed previously. (J Spinal Cord Med;] 8:88–94)