Seizure semiology in temporal lobe vs. temporal plus epilepsy using intracranial EEG monitoring

Objectives:To utilize our tertiary center’s experience with Temporal lobe epilepsy (TLE) and Temporal plus epilepsy (TPE) cases and determine whether a correlation exists between ictal semiology signs, their localization/lateralization value after intracranial electroencephalography (EEG) monitoring, and surgical outcomes.Methods:A retrospective study was conducted among epilepsy patients who underwent resective surgery for TLE or TPE after intracranial EEG monitoring between January 2008 and December 2018 at King Faisal Specialist Hospital in Riyadh, Saudi Arabia. Data were retrieved for 464 patients; 181 had intracranial electrode monitoring.Results:Forty-eight patients with a mean age of 27 years (SD=8.4) were included; 15 patients had TPE. Auras were frequently reported, emotional auras, in the form of fear (35%). The localization/lateralization value of aura was statistically significant for TPE patients, including visual hallucinations and vertigo, lateralized to the left and right temporo-occipital, respectively (p=0.009 and <0.001). Early-onset ictal manual automatism, oral automatism, late-onset dystonic posture, and late head-turning were significant for TLE without significant lateralization value. The ictal onset zone’s localization was significant between the scalp and intracranial EEG findings in mesial TLE patients. The probability of seizure freedom (Engel class I) was 74%, 60%, and 67% at 2-year follow-up for mesial, lateral TLE, and TPE, respectively.Conclusion:Our results are consistent with previous studies and confirm the importance of ictal semiology signs in TLE and TPE. The addition of intracranial EEG monitoring in these cases helped improve the surgical outcomes.

Epilepsy is one of the most common neurological disorders, affecting approximately 70 million people globally.¹ Thirty percent of these patients have drug-resistant epilepsy,² and most cases referred for epilepsy surgery involve temporal lobe epilepsy (TLE).³ However, after standard temporal lobectomy, around 40% of these patients will experience recurrent seizures.⁴ A variety of explanations have been proposed for these surgical failures, including incomplete removal of the epileptogenic zone, additional contralateral focus (bilateral TLE), dual pathology (mesial and neocortical), and extended epileptogenic focus to the neighboring structures, including extratemporal or temporal plus epilepsy (TPE).⁵The TPE is defined as focal epilepsy with a complex epileptogenic network involving the temporal lobe and the surrounding areas, such as the orbitofrontal cortex, insula, operculum, and temporo-parieto-occipital junction.⁶ A thorough presurgical evaluation is required to delineate the epileptogenic zone for successful resective surgery. In phase I assessment, scalp video electroencephalography (EEG) monitoring, brain magnetic resonance imaging (MRI), and neuropsychological evaluation are needed. Further non-invasive investigations can be included if the initial results are discordant. To reach a well-demarcated epileptogenic focus requires intracranial monitoring, including the subdural grid, strips, and depth, which is known as phase II assessment.⁷ Seizure semiology is the first step in a presurgical evaluation, and ictal semiology and scalp-EEG results play a valuable role in distinguishing TLE from TPE.⁸ Patients with TLE are more likely to experience abdominal auras, ictal gestural automatism, and post-ictal amnesia. However, TPE patients are more likely to experience gustatory hallucinations, rotatory vertigo, auditory illusions, contralateral eye and head versions, piloerection, and ipsilateral tonic posturing. Similar findings were highlighted in a review of TPE cases.4 Furthermore, laryngeal and throat constriction and the atypical distribution of somatosensory symptoms at seizure onset have been found.4Although some studies have found a correlation between seizure semiology and intracranial EEG monitoring in TLE (mesial vs. lateral) vs. TPE, none evaluated lateralization values. This study aims to utilize our tertiary center’s experience with TLE and TPE cases and determine whether a correlation exists between ictal semiology signs, their localization/lateralization value after intracranial electroencephalography (EEG) monitoring and surgical outcomes. We also highlight the process of phase I presurgical assessment (including ictal/interictal scalp EEG, MRI, positron emission tomography [PET], and neuropsychology) in our center.     

Hepatoid esophagogastric adenocarcinoma and tumoral heterogeneity: a case report

Hepatoid adenocarcinoma of the stomach is an uncommon subtype of gastric cancer remarkably similar to hepatocellular carcinoma in histopathological analysis. It is also commonly associated with high serum alfa-fetoprotein and a poorer prognosis, despite the emergence of new therapeutic options. In recent years, next generation sequencing (NGS) technology has made it possible to identify and describe the genes and molecular alterations common to gastric cancer thereby contributing to the advancement of targeted therapies. A 62-year-old patient, with no prior risk factor for hepatocellular carcinoma (HCC), presented to the emergency room with dysphagia for solids, abdominal pain and weight loss of about 3 kilograms over 3 months. Histopathological analysis presented with disparities regarding HER2 and programmed death-ligand 1 (PD-L1) status in the primary and metastatic sites. We describe a case of a de novo metastatic, human epidermal growth factor receptor 2 (HER2) positive esophagogastric junction hepatoid adenocarcinoma. Although this is a rare subgroup of gastric cancer, treatment strategies were based in recent studies in immunotherapy and guided therapy, taking into consideration the molecular findings from the patient’s tumor NGS analysis. Data about HER2 and PDL1 heterogeneity were also reviewed. Despite the aggressiveness and rarity of this histology, the patient had a good response to treatment.     

Vitamin D supplements: The pharmacists’ perspective

ObjectiveThe purpose of this narrative review was to provide guidance for pharmacists concerning vitamin D supplementation.MethodsRelevant studies were identified in a search of MEDLINE/PubMed, EBSCOhost, and Google Scholar from January 1966 to September 2020 using the search terms vitamin D, vitamin D₂, vitamin D₃, calcitriol, and vitamin D deficiency. Abstracts were reviewed for relevance and, if relevant, full-text articles were retrieved and reviewed. References were checked, and citation searches using identified studies were conducted. The literature search included English-language studies involving administration of vitamin D monotherapy compared with placebo.ResultsSerum 25–hydroxyvitamin D levels of less than 12 ng/mL indicate a vitamin D deficiency. The Institute of Medicine recommends a daily intake of 600 IU of vitamin D in individuals aged up to 70 years and 800 IU in those aged above 70 years. Vitamin D is labeled for rickets, osetomalacia, hypophosphatemia (familial or secondary), renal osteodystrophy, and corticosteroid-induced osteoporosis. When used for these indications, vitamin D should be prescribed with appropriate monitoring by a qualified health care practitioner. There is evidence for vitamin D supplementation in individuals aged 75 years or older and in those with problems associated with mobility, gait, or balance. There is insufficient evidence to support vitamin D supplementation in the prevention of cardiovascular disease, cancer, asthma, chronic obstructive pulmonary disease exacerbations, new-onset type 2 diabetes, infectious lung diseases, cognitive dysfunction, Alzheimer disease, and depression, or in prenatal use.ConclusionPharmacists can provide evidence-based recommendations concerning the indications, dosing, monitoring, and adverse effects of vitamin D supplements.     

Dental arch parameters of the displacement and nondisplacement sides in subjects with unilateral palatal canine ectopia

Objective:To compare arch perimeter and teeth size, number, and shape between the two sides of the dental arch—the canine displacement side (DS) and the nondisplacement side (NDS)—in subjects with unilateral palatally displaced canine (PDC).Materials and Methods:Orthopantomograms (OPTs) of 240 subjects with unilateral PDC and 240 OPT matching controls were used. Additionally, study casts of 100 study subjects and 100 controls were used. The age of subjects ranged between 14 and 25 years. Dental casts were digitized and several parameters were recorded.Results:The transverse width from midpalatal line to the buccal segment and the palatal area on the DS was larger than that in the NDS (P < .05 to .001), with no difference in tooth size between both sides. Maxillary second premolars, canines, and lateral incisors in the PDC group were smaller than those in control group. Peg-shaped lateral incisors were significantly more frequent in the study group (P < .001).Conclusions:The transverse width of the DS was larger than that of the NDS. Both sides were generally smaller than those of the control group. Tooth size in the DS was comparable to that in the NDS but smaller than those of the control group. A missing or peg-shaped lateral incisor was the most common reported anomaly.     

Healthcare personnel’s experience of reporting adverse drug reactions in Baghdad city: cross-sectional study

Background Adverse drug reactions (ADRs) are undesirable effects to drugs at doses normally used in the clinical setting for diagnosis, treatment or prophylaxis of diseases. Spontaneous ADR reporting is currently considered as a critical part of ADRs detection. Objective The study aims to assess the knowledge, attitude, and practice of healthcare providers towards adverse drug reaction reporting in public and private settings within the Baghdad area. Method We follow a quantitative cross-sectional study design, using a self-administered questionnaire to collect data from the healthcare providers regarding their reporting practice. Main outcome The outcome measures include the experiences of reporting of adverse drug reactions and the available systems, in addition to the expected benefits to clinical practice. Results Among 485 respondents, 114 were able to differentiate ADRs from side effects. About half of them (47.6%) recognized the availability of reporting systems and 43.3% knew how to report adverse drug reactions. 43.7% of the respondents mentioned that ADRs should be reported only when they are life-threatening. Among the 188 respondents who encountered ADRs, 145 reported the events to the accessible local authority. Conclusion The healthcare providers working in Baghdad healthcare institutions have a good attitude toward ADR reporting. There is a relatively below-standard reporting culture of the encountered adverse reactions. The inadequate knowledge about adverse reactions and the unavailability of reporting forms played a major role in discouraging healthcare professionals to detect and report ADRs.