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A festive treat — A Fo Ben is a glutton for well-designed, well-powered, randomised, blinded trials that answer long-standing clinical problems. A multinational team compared the efficacy and safety of three intravenous anticonvulsive agents for children and adults with convulsive status epilepticus that was unresponsive to treatment with benzodiazepines. A total of 384 patients were enrolled to receive levetiracetam, fosphenytoin and valproate. Interestingly, following enrolment, 10% were thought to have dissociative seizures. Remarkably, each drug had a very similar efficacy and a very similar adverse event profile . It is worth noting the dosing range (20–40–60): 20 mg/kg fosphenytoin, 40 mg/kg valproate and 60 mg/kg levetiracetam. A Fo Ben suspects we may be often underdosing levetiracetam in emergency departments in the UK.
N Engl J Med 2019;381(22):2103–2113.
Life imitating art
There are plenty of examples of opticians with thick-lensed spectacles or dentists with terrible nashers. More unusual are the common examples of experts who develop their ‘own disease’, perhaps the best example of which was the striking memoir of Jim Morrow published in Practical Neurology a few years ago. Writing in the Lancet, Udo Kischka, Consultant in neurorehabilitation, describes his own intracerebral haemorrhage. Extracting isolated ‘bon mots’ does not do justice to his report: ‘I considered myself a stroke specialist, but soon realised how little I knew’, and ‘Hemianopia was a revelation’ begins one paragraph; then the moment we all dread—being admitted on to the ward where you were previously a Consultant. He describes the terror of being so needy and despite necessitating hoist transfers, retaining as much dignity as is possible. Among the plethora of learning points from this lived experience is the disability that comes from fatigue and apathy.
Epilepsy is the consequence of the brain playing see-saw between excitation and inhibition. So, clearly stimulating the brain should not halt seizures, and only the foolish would study the role of the cerebellumin seizures… right? A team set out to study on-demand optogenetic excitationof glutamatergic neurons in the fastigial nucleus and whether it could inhibithippocampal seizures (in mice). Intriguingly, both optogenetic excitation andinhibition of cerebellar cortical output neurons, Purkinje cells, have beenpreviously shown to attenuate seizures. In this study there was greater seizureinhibition when selectively targeting glutamatergic fastigial neurons than whena less specific approach was used.
J Physiol. 2019 doi: 10.1113/JP278747.
Internet gurus tell us about the interconnectedness of everything and how the future is wearable technology, but have we really found a medical benefit of this yet? A total of 419 297 people wore an Apple watch for an average of 117 days each; 0.5% had an irregular pulse detected. A total of 2161 participants were sent out an ECG patch; 450 returned them and had analysable data. Atrial fibrillation was detected in 34%. This large project was notable for being a ‘siteless’ study where all consent was taken via an app; somehow both interconnected and hands-free.
N Engl J Med. 2019;381(20):1909–1917.
What has no licensed treatments but affects 20% of hospital admissions? The same condition increases mortality, and a recent systemic review does not support the routine use of any of the currently used medications. The disorder is delirium and the drugs are antipsychotics. Sixteen randomised control trials and 10 observational studies were scrutinised and reported no evidence to support antipsychotics (versus placebo) and warned against the harmful cardiac effects of antipsychotics. It must be time for a new approach to delirium?
Ann Intern Med. 2019;171(7):485-495.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.
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