Gary N. McAbee

Acute pancreatitis in children from Valproic acid: case series and review

Valproic acid (VPA) is a commonly prescribed medication approved for use in the United States for epilepsy, migraine, and bipolar disorder. Although the common adverse effects associated with VPA are typically benign, less common but more serious adverse effects can occur. These include hepatotoxicity, teratogenicity, possible polycystic ovaries with the potential for sterility or carcinogenesis, and pancreatitis. A characteristic clinical profile has been determined for several of these adverse effects. We report four children with VPA-induced pancreatitis, one of which was fatal, and review the literature. Three of these children presented within a 4-year period (1995-1999) at the same institution. Because previous reviews have included either a small number of patients, or both pediatric and adult patients, we reviewed only pediatric cases to minimize any effect from adults with more serious co-existing medical illnesses. We attempted to determine the following: (1) if there are any characteristics that are predictive of pancreatitis and whether it will be fatal; (2) whether different clinical and laboratory characteristics exist for nonfatal vs fatal cases; and (3) if a specific pediatric patient profile, similar to that with VPA associated hepatotoxity or polycystic ovary-androgenism syndrome, could be identified.

Prolonged survival with hydranencephaly: report of two patients and literature review

Infants with hydranencephaly are presumed to have a reduced life expectancy, with a survival of several weeks to months. Rarely, patients with prolonged survival have been reported, but these infants may have had other neurologic conditions that mimicked hydranencephaly, such as massive hydrocephalus or holoprosencephaly. We report two infants with prenatally acquired hydranencephaly who survived for 66 and 24 months. We reviewed published reports to ascertain the clinical and laboratory features associated with survival of more than 6 months. This review demonstrates that prolonged survival up to 19 years can occur with hydranencephaly, even without rostral brain regions, with isoelectric electroencephalograms, and with absent-evoked potentials. Finally, the ethical aspects of these findings, as they relate to anencephaly and organ transplantation, are discussed.

Tourette syndrome associated with unilateral cystic changes in the gyrus rectus.

Brain magnetic resonance imaging of an 11-year-old male with Tourette syndrome demonstrated multicystic changes predominately in the gyrus rectus of the left frontal lobe. Other brain regions, including the basal ganglia, were normal. He did not have any symptoms of the comorbid conditions associated with Tourette syndrome, such as attention-deficit disorder or obsessive-compulsive disorder. The possible neurobiologic connection between Tourette syndrome and the gyrus rectus and its interconnecting pathways is discussed.

Malpractice Risks Associated With Prescribing Medication for Chronic Headaches

An important medical issue relating to the treatment of chronic pain that is due to headache is the concern for the physical dependence or addiction (ie, psychological dependence) that can occur in some patients who overuse these medications. l,* An evolving legal cause of action in medical malpractice suits relates to this potential risk for addiction to the patients, and the malpractice risk to the prescribing physician for causing, or contributing to, that addiction. Medications containing narcotic-sedatives such as barbiturates (eg, butalbital), codeine, butorphanol, meperidine, pentazocine, propoxyphene, morphine/hydromorphone, and benzodiatepines have all been used alone, and in combination, as treatment for persistent migraine and “mixed” headache syndrome.3A Three factors associated with the use of these medications relate to the possibility of subsequent addiction. First, tolerance to narcotic-sedative analgesics can occur with excessive use.5 Second, discontinuation of analgesic medication that has been used excessively can lead to the analgesic rebound syndrome which induces the palliative use of even more analgesics. 4c5 Third, psychological addiction can occur in the absence of either a state of tolerance or physical dependence? Many patients with chronic headaches report that they use daily analgesics.Z8 Conversely, studies suggest that many patients with medication dependence or abuse were being treated for a primary complaint of headaches.*eg Thus, some authorities recommend restricted use of analgesic medications for relief of headache, ranging from once per weeklo {for narcotics as an emergency

Hot Water-Induced Migraine Syndrome: Further Evidence of a Relationship between Migraine and Epilepsy

Introduction The relationship between migraine and epilepsy remains controversial, and a common basis has not yet been defined [1]. Up to 24% of adults have both conditions, but a close temporal relationship between headache and seizures occurs in only 3% [2, 3]. This combination may be more common in children, especially those with benign partial epilepsies with occipital paroxysms and, possibly, centrotemporal spikes (rolandic) [4]. Several clinical observations relate migraine to epilepsy, including the following: (1) migraine is more common in patients with seizures than in controls; (2) EEG abnormalities occur in patients with migraine who have not had seizures; (3) patients can have a seizure following onset of migraine; (4) both conditions may be preceded by an aura, and (5) anticonvulsants can be effective in both conditions [1, 2]. We report an adolescent with multiple episodes of a migraine headache syndrome which only occurred during a hot water shower. There were no definite features consistent with a seizure that occurred over a 4-year period. Hot water can precipitate seizures but, to our knowledge, has not been previously reported as a triggering agent of migraine.