Les compartimos las akerta medicas que se mencionaron en la clase del sabado
Se dejaran los links hacia los articulos de cada alerta medica, los cuales podran hacerles ganar puntos en su nota para el promedio final.
1. Requested DocAlert: First-Time Seizure: Management Tips From the AAN and American Epilepsy Society
Information sourced from AHRQ:
Evidence-based guideline: management of an unprovoked first seizure in adults: report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society.
https://www.neurology.org/content/84/16/1705.long
2.-Can Dextromethorphan plus Quinidine Reduce Agitation in Patients with Alzheimer Disease Dementia?
https://www.jwatch.org/na39119/2015/10/08/can-dextromethorphan-plus-quinidine-reduce-agitation
https://jama.jamanetwork.com/article.aspx?articleid=2442936
3.-Requested DocAlert: Picture Quiz Poll: A Schoolgirl With Lumpy, Bumpy Arms and Legs
https://www.epocrates.com/sites/default/files/res/dacc/2015/ErythemaNodosumBMJ1510.pdf
4.-Requested DocAlert: Influenza Vaccination: 2015-2016 CDC/ACIP Recommendations
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm
5.- Requested DocAlert: Consider ASD When ADHD Behaviors Occur in Young Children
When ADHD Behaviors Occur in Young Children, Consider Autism Spectrum Disorder
https://www.jwatch.org/na39147/2015/09/30/when-adhd-behaviors-occur-young-children-consider-autism
https://pediatrics.aappublications.org/content/135/2/e330.full
6.- Requested DocAlert: Respiratory Viruses Are Everywhere; Children More at Risk
https://www.jwatch.org/na39212/2015/10/09/respiratory-viruses-are-everywhere
7.- Requested DocAlert: Anxiety and Risk of Parkinson Disease
Risk of Parkinson’s disease following anxiety disorders: a nationwide population-based cohort study.
https://www.ncbi.nlm.nih.gov/pubmed/26031920
8.- Clinical Review
Febrile seizures
Nikhil Patel, Dipak Ram, Nina Swiderska, et al.
Correspondence to: R W Newton richard.newton@cmft.nhs.uk
[EXCERPTS]
The International League Against Epilepsy (ILAE) defines a febrile seizure as “a seizure occurring in childhood after one month of age associated with a febrile illness not caused by an infection of the central nervous system, without previous neonatal seizures or a previous unprovoked seizure, and not meeting the criteria for other acute symptomatic seizures.”1 The cumulative incidence of febrile seizures is estimated between 2% and 5% in the US and Western Europe,2 3 between 6% to 9% in Japan, and 14% in India and Guam.1 Febrile seizures have a peak incidence at 18 months and are most common between the ages of 6 months and 6 years.4 5 6
Was it a febrile seizure?
Take the child’s temperature after the seizure has ended. Beware an alternative diagnosis if the fever is less than 38.0 °C.7 The fever can occur at any time and sometimes after the seizure. Children with febrile seizures have higher temperatures with illness compared with febrile controls.6 Seizure types include tonic or clonic movement which may be asymmetrical or brief suspensions of awareness. Other events may mimic febrile seizures, and careful history-taking helps distinguish these: fever may be associated with rigors or delirium; a period of pallor and low tone before tonic or clonic movement is suggestive of syncope or a reflex anoxic seizure. Clusters of afebrile seizures in the setting of gastroenteritis, particularly rotavirus infection, are a separate but well recognised entity.
Seizure classification
[In 2010 the ILAE proposed that febrile seizures could be organised by typical age at onset (that is, infancy and childhood).] Conventionally febrile seizures have been classified as simple or complex based on duration, recurrence, and the presence of focal features (see table). Most febrile seizures are generalised tonic-clonic seizures, and about 30-35% of febrile seizures have one or more complex features (focal onset, duration >10 minutes, or multiple seizures during the illness episode).6 Febrile status epilepticus, a subgroup of complex febrile seizures with seizures lasting more than 30 minutes, occur in about 5% of cases.6
Key features differentiating simple febrile seizures from complex febrile seizures
Feature
Simple febrile seizures
Complex febrile seizures
Duration
Short (15 minutes)
Focal features
Generalised tonic-clonic features are typical (stiffening of muscles followed by rhythmical jerking or shaking)
Focal seizures with or without secondary generalisation
Recurrence
No recurrence within the next 24 hours
May present with repetitive seizures during the next 24 hours
Postictal features
No postictal pathology
Todd’s paresis may be present (a period of paresis of affected limbs)
How can I be sure this is really a febrile seizure?
A major concern in any febrile child with a seizure is the possibility of central nervous system infection. A seizure in a febrile child can be the only presentation of bacterial meningitis.29 30 Since the introduction of vaccines for Haemophilus influenzae type b and Streptococcus pneumoniae, the incidence of bacterial meningitis is substantially reduced. According to a recent systematic review, the overall risk of bacterial meningitis was 0.2% in children with an apparent first simple febrile seizure and 0.6% in children with complex febrile seizure.31
As the incidence of bacterial meningitis is low in children with febrile seizures, a lumbar puncture is not indicated routinely. The diagnosis of bacterial meningitis should be based on detailed history taking, thorough clinical examination and the exercise of clinical judgement (see box 1).
Box 1: Red flags suggestive of central nervous system infection31 32 33
History of irritability, decreased feeding, or lethargy
Complex febrile seizures
Any physical signs of meningitis or encephalitis (bulging fontanelle, neck stiffness, photophobia, focal neurological signs)
Prolonged postictal altered consciousness or neurological deficit (>1 hour)
Drowsiness with limited response to social cues (lasting >1 hour)
Previous or current treatment with antibiotics
Incomplete immunisation in children aged 6-18 months against Haemophilus influenzae b and Streptococcus pneumoniae
In children What other investigations should be considered?
When central nervous system infection is excluded, the clinician should consider other causes of fever. Although it has been shown that febrile seizures are more likely to occur with respiratory illnesses,34 any febrile illness may be the cause. Viral upper respiratory infection, otitis media, pneumonia, and gastroenteritis are all common. Urine analysis and urine culture should be considered if a source of infection is not otherwise identifiable.33 Blood tests (urea and electrolytes profile, full blood count) do not need to be performed routinely. The National Institute for Health and Care Excellence (NICE) offers guidance on the investigation of the febrile child.7
Is there a link between febrile seizures and epilepsy?
Febrile seizures can be the first presentation of epilepsy. Careful history and examination will help identify children with an underlying neurological condition. Suspicion of epilepsy should be raised if there was no compelling history of fever, if the seizure was complex or there were postictal signs, or if the child’s development is not age appropriate. Although electroencephalography is not routinely indicated, neuroimaging should be considered in those with prolonged postictal neurological deficits or recurrent complex febrile seizures, and in children with developmental impairment or with signs of a neurocutaneous syndrome.35
What is the risk of recurrence of febrile seizures?
Parents should be told that febrile seizures may reoccur. Several cohort studies have found that up to a third of children have a recurrence, and 75% of these occur within one year.8 36 Risk factors for and risk of recurrence after an initial febrile seizure are provided in box 2. Children with all of these risk factors have up to an 80% chance of having further episodes. Children with none of the cited risk factors have a 4% chance of having a further febrile seizure.8 36 37 38
A positive family history of epilepsy is not consistently associated with increased recurrence of simple febrile seizure.41
Box 2: Risk factors for recurrent febrile seizures10 36 37 38 39 40
Age at onset under 18 months
History of febrile seizure in a first degree relative
Relatively low grade of fever associated with seizure (<39 °C)
Shorter duration of fever before seizure (3 years) and febrile seizures with a temperature of <39 °C were also significant predictors of unprovoked seizures.46 Knowledge of these risk factors [aids] the counselling of parents, who often ask if their child is going to develop epilepsy. When should we use benzodiazepines? After a first prolonged febrile seizure, or in a child with other factors giving a high risk of recurrence, benzodiazepines (buccal midazolam or rectal diazepam) should be provided to parents on discharge. These should be used in case of an emergency at home, and parents should be given clear advice regarding when and how to use these rescue medications. The usual recommendation is that rescue medication is given if a seizure is continuing beyond 5 minutes from onset.43 56 Most febrile seizures last less than 10 minutes. Even recurrent brief febrile seizures do not warrant treatment as there is no increased risk of brain injury. Febrile status epilepticus (seizure >30 minutes) encompasses 5% of febrile seizures6 and represents a quarter of all paediatric status epilepticus.40 It is a risk factor for further prolonged seizures. There may be associated hypoxia, and early termination is important.
The prospective FEBSTAT study included 179 children, aged from 1 month to 6 years presenting with a febrile seizure lasting 30 minutes or more. The study demonstrated that the longer a seizure continues, the less likely it is to stop spontaneously.57 58 Febrile status epilepticus is not often treated in the time before hospital admission, reflecting concern that benzodiazepines can cause respiratory depression. FEBSTAT showed the need for respiratory support was actually more common in children with longer seizures. Other studies showed that benzodiazepine treatment of seizure either before hospital arrival or in the emergency department setting did not increase the need for intubation.59 60
Is there a role for prophylactic drug management?
Antipyretics and antiepileptic drugs have been used to prevent recurrence. These interventions were the subject of a Cochrane review in 2012.65 The systematic review demonstrated no advantage in the use of intermittent ibuprofen, diclofenac, or paracetamol versus placebo in preventing further febrile seizures,65 a conclusion also drawn by a more recent systematic review.12 This may be particularly useful as advice for worried parents, who may blame themselves for not administering antipyretics before their child had a febrile seizure.
Given the usually benign nature of febrile seizures and the high risk of adverse effects with medications, there currently is no role for prophylactic antiepileptic drugs in preventing recurrent febrile seizures. No benefit has been shown for the use of intermittent oral and rectal diazepam, phenytoin, phenobarbitone, sodium valproate, pyridoxine, and intermittent phenobarbitone versus placebo in preventing febrile seizures. Intermittent clobazam versus placebo at 6 months showed an apparent benefit, but in the control group the recurrence rate of febrile seizures was extremely high at 83.3%, and this result therefore needs replication.65 More importantly, adverse medication effects were found in up to 30% of recipients.
What is the role of antipyretics?
Tepid sponging is no longer recommended for febrile children as it may raise core body temperature. Children should not be underdressed nor overdressed.7 Antipyretics should be used to relieve the distress of feeling ill.7 Prophylactic use does not reduce recurrence risk.
When to seek specialist opinion
Most children with febrile seizures do not require hospital admission. The incidence of bacterial meningitis is low, and clinical features can help distinguish between the two.
We recommend that children with febrile seizures should have further assessment by a paediatrician (or general practitioner with suitable training, depending on the setting) if they develop
First febrile seizure
Decreased consciousness level before seizure (use of the Paediatric Glasgow Coma Score is encouraged for an objective record)
Slow recovery with abnormal behaviour or drowsiness after seizure (consider referral if normal neurological or mental state is not achieved within one hour)
Clinical signs of meningism (irritability, neck stiffness, photophobia, headache)
Complex febrile seizures
Focal neurological deficit on examination
Unwell child with features of septicaemia
Unexplained cause of fever
[Selected References]
https://www.bmj.com/content/bmj/suppl/2015/08/18/bmj.h4240.DC1/febrile_seizures_v19_web.pdf
https://www.bmj.com/content/351/bmj.h4240
Copyright © 2015 BMJ Publishing Group Ltd
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PREGUNTAS DE CME
Procedimiento
Lea cuidadosamente las siguientes instrucciones:
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Para contestarlas debe ingresar su nombre correo electronico y contestar una pregunta aritmetica que esta en esa pagina
Luego en el espacio de comentario conteste las siguientes preguntas:
Lea y contesta las siguientes preguntas (OJO LAS RESPUESTAS DEBEN DE SER EN ESPAÅOL, NO COPIE LAS RESPUESTAS DE OTROS PUES ES PARA SU APRENDIZAJE)
Pregunta numero 1: tiene 11 dificultades:
https://www.neurology.org/content/84/16/1705.long
1.1 For the adult presenting with an unprovoked first seizure, does immediate treatment with an AED change the short-term (2-year) prognosis for seizure recurrence?
1.2 For the adult presenting with an unprovoked first seizure, does immediate treatment with an AED change the short-term (2-year) prognosis for seizure recurrence?
1.3 For the adult who presents with an unprovoked first seizure, what are the nature and frequency of AEs with AED treatment?
Cuales son las 8 recomendaciones y el nivel de evidencia
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
Pregunta numero 2
Can Dextromethorphan plus Quinidine Reduce Agitation in Patients with Alzheimer Disease Dementia?
https://www.jwatch.org/na39119/2015/10/08/can-dextromethorphan-plus-quinidine-reduce-agitation
Pregunta numero 3
3.-Requested DocAlert: Picture Quiz Poll: A Schoolgirl With Lumpy, Bumpy Arms
An 11 year old girl presented to her general practitioner with painful skin lesions on her arms (fig A) and legs (fig B). She had a three week history of an upper respiratory illness and had been started on amoxicillin for presumed lower respiratory tract infection. Three days after starting treatment, she re-attended with a rash on her arms and legs; her parents were worried that it was caused by a drug allergy. Apart from a low grade fever (38oC), she was well and her observations and examination were otherwise unremarkable. What is the diagnosis?
https://medicinainternaelsalvador.com/alertas-medicas-cme/
Pregunta 4
4.1 For 2015 16, ACIP recommends the following
5 recomendaciones :
respuesta en español
4.2
4.3
4.4
4.5
4.6
4.2 Influenza Vaccination of Persons With a History of Egg Allergy
6 recomendaciones : respuesta en español
4.7
4.8
4.8
4.10
4.11
4.12
Pregunta numero 5
When ADHD Behaviors Occur in Young Children?, when consider Autism Spectrum Disorder?
https://www.jwatch.org/na39147/2015/09/30/when-adhd-behaviors-occur-young-children-consider-autism
Pregunta 6.
Respiratory Viruses Are Everywhere; Children More at Risk
Cuales son los 7 resultados de este estudio longitudinal. Respuesta en español
https://www.jwatch.org/na39212/2015/10/09/respiratory-viruses-are-everywhere
Pregunta 7 tiene 6 dificultades:
Anxiety and Risk of Parkinson Disease
Risk of Parkinson s disease following anxiety disorders: a nationwide population-based cohort study.
7.1 Cual es coeficiente de riezgo ajustado (Adjusted Hazard Ratio) de padecer de PD sin ansiedad?:
7.2 Con ansiedad generalizada? Valor global o crudo:
7.3 Con ansiedad leve?
7.4 Con ansiedad moderada?
7.5 Con ansiedad severa?
7.6 Cual de estos grupos tiene rechazo de hipotesis nula ?
https://www.ncbi.nlm.nih.gov/pubmed/26031920
Pregunta 8 tiene 10 dificultades
8.- Clinical Review
Febrile seizures
8.1 Was it a febrile seizure?
8.2 what is the seizure classification?
8.3 How can I be sure this is really a febrile seizure?
8.4 What other investigation should be considered?
8.5 is there a link between febrile seizures and epilepsy?
8.6 What is the risk of febrile seizures?
8.7 what is the risk of developing epilepsy?
8.8 when should be considered benzodiazepines?
8.9 Is there a role for prophylactic drug management?
8.10 What is the role of antipyretics?
Fecha limite de resolucion de cuestionario viernes 13 de noviembre 2015
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