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Abstract Background The Basic Health Unit (Unidade Básica de Saúde - UBS, in Portuguese) is the first point of contact in the public healthcare system for people with epilepsy. Primary care professionals need to appropriately diagnose, treat, and refer, if necessary, to tertiary services. Objective To evaluate the knowledge of UBS professionals on the management of patients with epilepsy in Rio de Janeiro. Methods Online questionnaires were performed on the topic of epilepsy before and after exposure to classes taught by epileptologists. Results A total of 66 doctors participated, 54.5% of whom were residents or trained in family medicine. The majority had from 1 to 3 years of practice. Insecurity prevailed in the management of pregnant women and the elderly. Around 59.1% of the participants referred patients with seizures without examinations. A total of 78% of the participants did not correctly classify seizure types, and 2/3 did not define drug-resistant epilepsy. Induction and broad-spectrum drugs were common. The therapeutic decision depended on availability in the basic health unit (UBS) (81.8%), dosage (60.6%), side effects (34.8%), and age (36.4%). Comorbidities and sex influenced 1/4 of the sample. For 23% of the participants, the type of crisis did not affect the choice. Regarding typical non-pharmacological options, 75% of the participants were aware of cannabidiol, 40.9% of surgery, 22.7% of ketogenic diet, and 22.8% of deep brain stimulation/vagus nerve stimulation (DBS/VNS). A total of 90.2% indicated the need for training. Conclusion There are deficits in the knowledge of UBS professionals in the management of epilepsy. Specialized training is imperative to optimize the care offered within SUS.
Resumo Antecedentes A Unidade Básica de Saúde (UBS) é o primeiro contato no sistema público de saúde para pessoas com epilepsia. Profissionais de atenção primária precisam diagnosticar, tratar e encaminhar adequadamente, se necessário, a serviços terciários. Objetivo Avaliar o conhecimento dos profissionais das UBSs sobre o manejo de pacientes com epilepsia no Rio de Janeiro. Métodos Foram realizados questionários online sobre o tema da epilepsia pré e pós exposição a aulas ministradas por epileptólogos. Resultados Participaram 66 médicos, sendo 54,5% residentes ou formados em medicina da família. A maioria tinha de 1 a 3 anos de prática. A insegurança prevaleceu no manejo de gestantes e idosos. Cerca de 59,1% dos participantes encaminhavam pacientes com crises sem exames. Um total de 78% dos participantes não classificou corretamente tipos de crises, e 2/3 não definiram epilepsia farmacorresistente. Fármacos indutores e de amplo espectro foram comuns. A decisão terapêutica dependeu da disponibilidade na Unidade Básica de Saúde (UBS) (81,8%), posologia (60,6%), efeitos colaterais (34,8%) e idade (36,4%). Comorbidades e sexo influenciaram 1/4 da amostra. Para 23% dos participantes, o tipo de crise não afetou a escolha. Quanto a opções não farmacológicas típicas, 75% conheciam o canabidiol, 40,9% a cirurgia, 22,7% a dieta cetogênica, 22,8% a estimulação cerebral profunda/estimulação do nervo vago (ECP/ENV). Um total de 90,2% dos participantes indicou necessidade de treinamento. Conclusão Há déficits no conhecimento dos profissionais das UBSs no manejo da epilepsia. O treinamento especializado é imperativo para otimizar o cuidado oferecido no âmbito do SUS.
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The infection caused by the new coronavirus had its first case described in December 2019, in Wuhan, China, and reached a pandemic status in March 2020. Since then, knowledge about the different aspects of this infection has evolved, as well as increased reports concerning related neurological manifestations. Thus, the neurologist assumes a fundamental role in the care of these patients, who may have a clinical phenotype that goes beyond respiratory aspects. In the present study, we highlight the data available in the literature so far regarding the main neurological implications related to COVID-19 infection, in addition to calling attention for some aspects related to patients with previous neurological diseases who contract this infection.
A infecção causada pelo novo Coronavírus teve seu primeiro caso descrito em dezembro de 2019, em Wuhan, China e alcançou o status de pandemia em março de 2020. Desde então, o conhecimento sobre os diferentes aspectos da referida infecção evolui assim como aumentam relatos de manifestações neurológicas relacionadas. Assim, o neurologista assume papel fundamental na assistência desses pacientes, que podem ter um fenótipo clínico que ultrapassa os aspectos respiratórios. No presente estudo, destacamos os dados disponíveis na literatura até o presente momento no tocante às principais implicações neurológicas relacionadas à infecção pelo COVID-19, além de destacar alguns aspectos relativos aos pacientes com doenças neurológicas prévias que contraem a referida infecção.
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Humanos , COVID-19/complicações , Doenças do Sistema Nervoso/virologia , Fatores de Risco , COVID-19/tratamento farmacológicoRESUMO
In February 2020, the pandemic disease designated COVID-19, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has shown to be able to cause severe illness in some patients. Recent studies have hypothesized that the SARS-CoV-2 exploits the angiotensin-converting enzyme 2 (ACE2) receptor to gain entry inside the cells and so reach the central nervous system1. Amid this context, we have about 50 million people with epilepsy taking antiseizure drugs (ASDs) and or other medications (eg.: steroids, Cannabidiol, etc.) that are at risk to be infected by SARS-CoV-2 virus. So, we did an extensive review in the literature searching for recent studies that had explored the effects of the role of SARS-CoV-2 infection and epilepsy. We did not find evidence of poor outcomes between epilepsy and COVID-19. Regarding ASDs, we have found that enzyme inducers and inhibitors can have significant interactions with drugs that have been used to treat COVID-19 such as antiretrovirals, antibiotics, and antimalarial drugs. In contrast, others have fewer or no interactions with them as such as benzodiazepines, Lamotrigine, Levetiracetam, Topiramate, Perampanel, and so on. Besides that, the management of seizures in epileptic patients and status epilepticus should not be different from the usual protocol. However, the acknowledgment of these potential drug interactions could help in the right choice of ASDs, and also be aware of potential risk drug combinations and the importance in some cases of close monitoring of serum levels and adverse events.
Desde de Fevereiro de 2020, a doença pandêmica conhecida como COVID-19, causada pelo Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) tem se mostrado capaz de acometer gravemente alguns pacientes. Estudos recentes levantaram hipóteses de que o SARSCoV-2 explora o receptor da enzima conversora de angiotensina 2 (ACE2) para entrar no interior das células e atingir o sistema nervoso central1 . Nesse contexto, temos cerca de 50 milhões de pessoas com epilepsia em uso de medicações antiepilépticas (DAEs) e ou outras medicações (como corticoesteroides, Canabidiol, etc.). Por isso, fizemos uma extensa revisão na literatura, buscando estudos recentes que exploraram os efeitos do papel da infecção por SARS-CoV-2 e da epilepsia. Até o momento, não há evidências de que pessoas com epilepsia apresentam prognóstico ruim no que se refere ao COVID-19. No que se refere aos antiepilépticos, foi encontrado que indutores e inibidores enzimáticos são os que apresentam mais interação medicamentosa com drogas utilizadas no tratamento do COVID-19, tais como antirretrovirais, antibióticos, e drogas antimaláricas, enquanto outras apresentam pouca ou nenhuma interação com esses. Além disso, o manejo de crises epilépticas e estado de mal epiléptico não deve diferente do protocolo usual. No entanto, o reconhecimento das potenciais interações medicamentosas nesse contexto pode auxiliar na escolha correta do antiepiléptico, e alertar sobre os potenciais riscos de combinação entre drogas e a importância de em alguns casos monitorizar de perto os níveis séricos e eventos adversos.
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Humanos , Epilepsia/tratamento farmacológico , COVID-19/tratamento farmacológico , Antivirais/uso terapêutico , Fatores de Risco , Interações Medicamentosas , Epilepsia/complicações , COVID-19/complicações , Anticonvulsivantes/uso terapêuticoRESUMO
PURPOSE: Temporal lobe epilepsy (TLE) is the most common variety of focal epilepsy among adults. The neuroinflammatory mechanisms of epilepsies may be involved in the genesis of seizures and refractory epilepsies, particularly in the case of progressive syndromes such as TLE associated with mesial hippocampal sclerosis (TLE-HS). The goal of the present study is investigate the genetic profile of susceptibility of individuals with TLE-HS by analyzing the possible association of TLE-HS with human leukocyte antigen (HLA) DRB1, DQA1 and DQB1 alleles. METHODS: Peripheral blood samples were collected from 42 individuals with pharmacoresistant TLE-HS and 89 healthy controls. The typing of the HLA class II alleles from DRB1, DQB1, and DQA1 loci were analyzed using sequence-specific primer-polymerase chain reaction (SSP-PCR) and identified through sequencing. Statistical analysis of relative allele frequencies was performed using an Excel spreadsheet; p-value, relative risk (RR), and odds ratio (OR) were calculated using the software Epi Info 6.0. p-values <0.05 following Bonferroni's method correction were considered statistically significant. RESULTS: HLA-DRB1*13:02 was the only allele with a statistically significant difference (p=0.01) in frequency between patients and controls. However, the significance was lost following Bonferroni's method correction (p=0.44). The remainder of the alleles in the HLA-DRB1, HLA-DQB1 and HLA-DQA1 regions did not exhibit any significant association. CONCLUSION: The allele HLA DRB1*13:02 has exhibited a tendency to behave as a susceptibility factor for TLE-HS.
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Epilepsia Resistente a Medicamentos/genética , Epilepsia do Lobo Temporal/genética , Predisposição Genética para Doença , Cadeias alfa de HLA-DQ/genética , Cadeias beta de HLA-DQ/genética , Cadeias HLA-DRB1/genética , Adolescente , Adulto , Idoso , Epilepsia Resistente a Medicamentos/patologia , Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsia do Lobo Temporal/patologia , Epilepsia do Lobo Temporal/fisiopatologia , Feminino , Frequência do Gene , Estudos de Associação Genética , Hipocampo/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Esclerose , Adulto JovemRESUMO
Epilepsy and syncope are clinical conditions with high prevalence rates in the general population, and the differential diagnosis between them is difficult. Objective To assess the frequency of syncope in patients diagnosed with drug-resistant epilepsy (DRE) without appa-rent heart disease, to investigate the relationship between clinical and electroencephalographic (EEG) changes, and to verify the role of the inclination test (IT). Method An open, prospective study from 2004 to 2006, including 35 consecutive patients from the Epilepsy Program of Hospital Universitário Clementino Fraga Filho who were diagnosed with DRE without apparent heart disease. Results The frequency of syncope was 25.7% (n=9), with a significant prevalence in women. Vasovagal syncope (VVS) was the most frequent diagnosis. Conclusion We found a significant association between syncope and the presence of autonomic symptoms (p=0.005). The IT plays an important role in the differential diagnosis of patients with DRE presenting with autonomic symptoms, regardless of EEG results and brain magnetic resonance imaging (MRI) abnormalities.
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Epilepsia/diagnóstico , Síncope/diagnóstico , Adolescente , Adulto , Diagnóstico Diferencial , Resistência a Medicamentos , Eletroencefalografia , Epilepsia/tratamento farmacológico , Epilepsia/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Síncope/fisiopatologia , Teste da Mesa Inclinada , Adulto JovemRESUMO
Epilepsy and syncope are clinical conditions with high prevalence rates in the general population, and the differential diagnosis between them is difficult. Objective To assess the frequency of syncope in patients diagnosed with drug-resistant epilepsy (DRE) without apparent heart disease, to investigate the relationship between clinical and electroencephalographic (EEG) changes, and to verify the role of the inclination test (IT). Method An open, prospective study from 2004 to 2006, including 35 consecutive patients from the Epilepsy Program of Hospital Universitário Clementino Fraga Filho who were diagnosed with DRE without apparent heart disease. Results The frequency of syncope was 25.7% (n=9), with a significant prevalence in women. Vasovagal syncope (VVS) was the most frequent diagnosis. Conclusion We found a significant association between syncope and the presence of autonomic symptoms (p=0.005). The IT plays an important role in the differential diagnosis of patients with DRE presenting with autonomic symptoms, regardless of EEG results and brain magnetic resonance imaging (MRI) abnormalities. .
Epilepsia e síncope são condições clínicas com alta prevalência na população geral e, às vezes, o diagnóstico diferencial entre elas é difícil. Objetivo Investigar a frequência de síncope em pacientes diagnosticados com epilepsia fármaco resistente (EFR), sem doença cardíaca aparente; investigar a relação entre alterações clínicas e eletrencefalográficas; verificar o papel do teste de inclinação (TI). Método Estudo aberto prospectivo, realizado de 2004 a 2006, incluindo 35 pacientes consecutivos do Programa de Epilepsias do Hospital Universitário Clementino Fraga Filho, diagnosticados com EFR, sem doença cardíaca aparente. Resultados A frequência de síncope foi de 25,7% (n=9), com prevalência significativa em mulheres. Síncope vasovagal (SVV) foi o diagnóstico mais frequente. Conclusão Encontramos uma significativa associação entre síncope e a presença de sintomas autonômicos (p=0,005). O TI tem importante papel no diagnóstico diferencial de pacientes com diagnóstico de EFR que apresentam sintomas autonômicos, a despeito de alterações eletrencefalográficas e de ressonância magnética do crânio. .
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Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Epilepsia/diagnóstico , Síncope/diagnóstico , Diagnóstico Diferencial , Resistência a Medicamentos , Eletroencefalografia , Epilepsia/tratamento farmacológico , Epilepsia/fisiopatologia , Estudos Prospectivos , Síncope/fisiopatologia , Teste da Mesa InclinadaRESUMO
OBJECTIVE: To assess the prevalence and the profile of adverse events (AE) of natalizumab in patients with multiple sclerosis (MS). METHODS: Data collection from neurologists attending to patients with MS at specialized units in Brazil. RESULTS: Data from 103 patients attending the infusion centers of 16 MS units in 9 Brazilian states were included in the study. The total number of infusions was 1,042. Seventy-nine patients (76.7%) did not present any AE. Twenty-four patients (23.3%) presented only mild AE. There were three major AE, including two deaths. These three occurrences, although not necessarily being drug-related, must be taken into consideration. CONCLUSION: The profile of AEs for natalizumab shows that 97% of patients have none or only mild AE. However, still due to safety worries, the use of this medication should be restricted to MS units under the care of specialized neurologists.
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Anticorpos Monoclonais Humanizados/efeitos adversos , Esclerose Múltipla/tratamento farmacológico , Adolescente , Adulto , Brasil , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Natalizumab , Estudos Retrospectivos , Adulto JovemRESUMO
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Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Anticorpos Monoclonais Humanizados/efeitos adversos , Esclerose Múltipla/tratamento farmacológico , Brasil , Estudos RetrospectivosRESUMO
Persistent neuroinflammation is implicated in the pathogenesis of seizures and neuronal degeneration of temporal lobe epilepsy (TLE). Circulating level of inflammatory cytokines was determined during inter-ictal period of 25 non-operated and 10 patients (OP) submitted to anterior temporal lobectomy. OP patients showed marked reduction of IL-1ß, TNFα, MIP-1α, but not IL-6 and TGF-ß1. Paired analysis done before and after lobectomy showed reduction of inflammatory cytokines but increased TGF-ß1 levels, and lack of seizures for more than 6 months. Maintenance of high TGF-ß1 and IL-6 cytokines in both groups suggests a role in down-regulation of neuroinflammation and promotion of brain tissue remodeling for neuronal reorganization.