Deciphering the surgical treatment gap for drug-resistant epilepsy (DRE): A literature review

Patients with drug-resistant epilepsy (DRE) rarely achieve seizure freedom with medical therapy alone. Despite being safe and effective for select patients with DRE, epilepsy surgery remains heavily underutilized. Multiple studies have indicated that the overall rates of surgery in patients with DRE have stagnated in recent years and may be decreasing, even when hospitalizations for epilepsy-related problems are on the rise. Ultimately, many patients with DRE who might otherwise benefit from surgery continue to have intractable seizures, lacking access to the full spectrum of available treatment options. In this article, we review the various factors accounting for the persistent underutilization of epilepsy surgery and uncover several key themes, including the persistent knowledge gap among physicians in identifying potential surgical candidates, lack of coordinated patient care, patient misconceptions of surgery, and socioeconomic disparities impeding access to care. Moreover, factors such as the cost and complexity of the preoperative evaluation, a lack of federal resource allocation for the research of surgical therapies for epilepsy, and difficulties recruiting patients to clinical trials all contribute to this multifaceted dilemma.     

Factors affecting endometrial and subendometrial blood flow measured by three-dimensional power Doppler ultrasound during IVF treatment

BACKGROUND: No information exists in the literature regarding the factors affecting the blood flow towards the endometrial and subendometrial regions during IVF treatment. METHODS: We examined the effect of women's age, their smoking habits, their type of infertility (i.e. primary or secondary) and parity, causes of infertility and serum estradiol (E2) concentration on endometrial and subendometrial blood flows as measured by a three-dimensional (3D) power Doppler ultrasound during IVF treatment. All patients received a standard long protocol of ovarian stimulation and serum E2 concentration was determined on the day of hCG. 3D ultrasound examination with power Doppler was performed on the day of oocyte collection to determine vascularization index (VI), flow index (FI) and vascularization flow index (VFI) of endometrial and subendometrial regions. RESULTS: The age of women, their smoking habits, their types of infertility and parity and causes of infertility had no effect on the endometrial and subendometrial 3D power Doppler flow indices. There was a negative correlation between serum E(2) concentration and endometrial FI (r = -0.109; P = 0.006). CONCLUSIONS: Endometrial blood flow in IVF treatment was negatively affected by serum E2 concentration only.     

Avidity of technetium 99m glucarate for the necrotic myocardium: In vivo and in vitro assessment

Background  Similar to other^99mTc-based infarct-avid agents,^99mTc-glucarate localizes in myocardial infarcts. Whether severely ischemic viable myocytes sequester^99mTc-glucarate is uncertain. To assess the infarct specificity, in vitro and in vivo studies were performed. Methods and Results  H9C2 embryonic rat cardiocytes cultured under normoxia (N) or hypoxia (H) for 24 hours in 7.5 μCi^99mTc-glucarate were compared with necrotic cardiocytes. Mean H/N ratio (3.0±0.004, mean±SD) was significantly less than that of the necrotic/N ratio (39.9±6.5,p<0.01). Reperfused myocardial infarction (MI) in 4 dogs confirmed by²⁰¹Tl, (0.5 to 1.0 mCi) scintigraphy were imaged serially, with simultaneously injected mixture of^99mTc-glucarate and¹¹¹In-antimyosin Fab. Infarcts were detected scintigraphically within 4 to 10 minutes with^99mTc-glucarate.¹¹¹In-antimyosin required more than 1 hour. Myocardial distribution at 5 hours showed a direct correlation between^99mTc-glucarate and¹¹¹In-antimyosin uptake (r=0.99,p<0.0001). Both^99mTc-glucarate (r=−0.777,p<0.0001) and¹¹¹In-antimyosin (r=−0.775,p<0.0001) were inversely related to²⁰¹Tl distribution. Conclusions  The near perfect correlation between^99mTc-glucarate and¹¹¹In-antimyosin uptake (r=0.99) in reperfused canine MI and the insignificant glucarate uptake by viable cardiocytes in vitro attest to the avidity of^99mTc-glucarate for the necrotic myocardium and favor its use as a specific early marker of myocyte necrosis in acute MI. Supported in part by SBIR grant 1R43-HL54410-01 and Molecular Targeting Technology, Inc.     

CT and MR imaging appearances of an extraosseous calcifying epithelial odontogenic tumor (Pindborg tumor)

We herein report a rare case of extraosseous calcifying epithelial odontogenic tumor with local aggressive behavior. CT and MR imaging showed the distinctive appearances of this histologic entity. We briefly discuss the radiologic features of calcifying epithelial odontogenic tumor and the relevant literature.     

Congenital intrathoracic stomach: short esophagus or hiatal hernia?

We present a rare case of congenital intrathoracic stomach due to short esophagus in a preterm infant. Antenatal ultrasound during the second trimester showed a tubular cystic structure in the posterior mediastinum. The diagnosis of congenital hiatal hernia was initially made. After birth, the diagnosis was confirmed to be intrathoracic stomach associated with a congenitally short esophagus by upper gastrointestinal contrast study and laparotomy. Features that suggest intrathoracic stomach secondary to congenital short esophagus over the relatively more common congenital hiatal hernia include early identification of the intrathoracic stomach during the second trimester and the consistent absence of an abdominal stomach bubble on antenatal ultrasound. The infant's condition could not be surgically repaired due to the extremely malformed and short esophagus and she subsequently died. This is in sharp contrast to the more surgically amenable and non-life-threatening congenital hiatal hernia. Early recognition of intrathoracic stomach associated with congenital short esophagus is important as it is associated with difficult management and significant postnatal complications. Fetal magnetic resonance imaging may be useful in this situation. The prognosis is cautiously guarded, and the parents should be appropriately counseled.     

Polycystic ovary syndrome in asian women

There is substantial heterogeneity of symptoms and signs among women with polycystic ovary syndrome (PCOS). In addition to different diagnostic criteria used, the ethnic background of women with PCOS may affect the clinical, hormonal, and metabolic characteristics of this condition. We present here studies related to the clinical, hormonal, and metabolic characteristics and response to the treatment of PCOS in Asia, which may be different from those in Western countries. It is important to take into consideration the ethnic background of patients in future studies related to PCOS.     

Evaluation of a point-of-care glucose meter for general use in complex tertiary care facilities

ObjectiveTo evaluate the performance of the StatStrip? glucose meter from Nova Biomedical for use in complex tertiary care facilities.MethodsPerformance evaluation was conducted in 6 clinical locations involving nurse end-users. Imprecision (CV) < 5% was considered acceptable. Ten substances were examined for potential analytical interferences at two levels and 3 glucose concentrations. Inaccuracy was determined by 386 paired glucose differences between glucose meter and laboratory reference analyses. Acceptability was based on CSLI/ISO15197 criteria. Potential clinical impact was classified under a 5-level severity scheme.ResultsImprecision varied from CV 2.4 to 4.9%. Significant interference was observed only for free hemoglobin at 10 g/L. 97% of paired glucose meter-laboratory differences met CSLI/ISO15197 criteria. All discrepant results had low severity scores.ConclusionThe StatStrip? glucose meter demonstrated acceptable imprecision and inaccuracy, and was relatively free from common interferences. It should be a good candidate for general use in complex tertiary care facilities.     

Pro-oxidative effects of Chinese herbal medicine on G6PD-deficient erythrocytes in vitro.

Glucose-6-phosphate dehydrogenase (G6PD)-deficient subjects are susceptible to chemical-induced oxidative haemolysis. Little is known concerning the haemolytic properties of Chinese herbal medicine on G6PD-deficient subjects. Our objective was to investigate the pro-oxidative effect of 18 commonly used Chinese herbal medicine (CHM) on human G6PD-deficient red blood cells. G6PD-deficient (n=10) and normal (n=10) whole blood samples were incubated with water extracts of CHM. The resulting levels of reduced glutathione (GSH) and methaemoglobin (MetHb) were determined by biochemical assays. Rhizoma Coptidis significantly reduced GSH level by 48.9+/-5.4% (at 1 mg/mL) in the G6PD-deficient erythrocytes (P<0.001) compared with the respective control group without challenge. Similar dose-dependent responses were observed at higher concentrations of Cortex Moutan, Radix Rehmanniae, Radix Bupleuri, Rhizoma Polygoni Cuspidati and Flos Chimonanthi (P<0.01, 5-10 mg/mL). In addition, the levels of MetHb were elevated significantly when challenged with Rhizoma Coptidis (2.8 fold at 5 mg/mL) and Cortex Moutan (3.4 fold at 10 mg/mL). This is the first report on the pro-oxidative action of CHM on G6PD-deficient blood samples in vitro as demonstrated by the decrease of GSH and increase of MetHb. G6PD-deficient subjects should restrain from excessive consumption of these pro-oxidative herbs.     

Puerperal hypertension, stroke, and seizures after suppression of lactation with bromocriptine

The "absolute safety" of bromocriptine as a drug of choice in suppression of lactation is questioned. Two cases of cerebrovascular events after the use of bromocriptine for lactation suppression are presented, and the available, pertinent literature is reviewed.