Savvas S. Papacostas

Caring and coping: The dementia caregivers

Objectives: Caring for a family member with Alzheimers disease is associated with increased burden and depression. Effective coping with the hardships and demands of caring may help to sustain the caregiver and lessen the effect of the stressors. The objective of this study was to examine caregivers’ coping styles and the relationship with reported levels of burden and depression. Method: A cross-sectional correlation study was employed. One hundred and seventy-two caregivers of patients suffering from Alzheimers type dementia participated in the study. All patients were recruited from neurology clinics. The Greek versions of four measuring instruments used were: the Memory and Behaviour Problem Checklist, the Burden Interview, the Centre for Epidemiological studies-Depression scale and the Ways of Coping Questionnaire. Results: Positive coping is negatively correlated with burden (r = −0.20) and wishful thinking strategies were related positively (r = 0.16). The relation between depression and positive coping strategies is highly significant (p < 0.01), whereas for burden the relation is significant (p < 0.05). Regression analyses showed that positive coping strategies are the most powerful, both in terms of predicting depression levels, and also in terms of moderating the effect of burden on depression. Conclusion: Positive coping approaches need to be developed by caregivers so as to continue their caring role.

Oxcarbazepine Versus Carbamazepine Treatment and Induction of Serum Lipid Abnormalities

Long-term treatment with carbamazepine is associated with many metabolic changes, including elevations in serum cholesterol, high-density lipoprotein, low-density lipoprotein, and triglyceride levels. Oxcarbazepine has been reported to be a preferable antiepileptic drug, when compared to carbamazepine with respect to its effects on lipid metabolism, especially cholesterol, high-density lipoproteins, and low-density lipoproteins. The case of a 16-year-old girl who developed high serum cholesterol and low-density lipoprotein levels on both of these medications successively, while triglyceride and high-density lipoprotein levels were unaffected, is reported. (J Child Neurol 2000;15:138-140).

Sleep hypoventilation syndrome and respiratory failure due to multifocal motor neuropathy with conduction block

Sleep hypoventilation syndrome and respiratory failure have been reported in association with a diverse spectrum of neuromuscular disorders. We report a patient with multifocal motor neuropathy with conduction block who presented with sleep hypoventilation, presumably due to bilateral phrenic neuropathy and was initially diagnosed to have obstructive sleep apnea syndrome. Once the correct diagnosis was made the patient was treated successfully with a combination of regular immunoglobulin and bilevel nocturnal ventilation. Delay in the administration of intravenous immunoglobulin resulted in respiratory failure. Muscle Nerve, 2011

Vestibular evoked myogenic potentials: the fuzzy picture of different stimulation types is beginning to come into focus.

Vestibular evoked myogenic potentials (VEMPs) are an easy and reliable way of evaluating function of the vestibular nervous system. Using reproducible sound stimuli of short duration and fast rise time, one can record evoked potentials either caudally through the brainstem towards the sternocleidomastoid muscle (cervical VEMPs or cVEMPs) or rostrally through the medial longitudinal fasciculus towards the extraocular muscle nuclei (ocular VEMPs or oVEMPs). Inferior vestibular nerve function is specific to cVEMPs, while superior vestibular nerve function is specific to oVEMPs (Rosengren et al., 2011). Various stimulation methods are currently available to record VEMPs. Originally, air-conducted sound in the form of clicks was used (Colebatch et al., 1994), followed by tendon tap stimulation to the forehead (Halmagyi et al., 1995), and then by short duration electrical (‘‘galvanic’’) stimuli (Watson and Colebatch, 1998). Bone-conducted vibration was then developed (Sheykholeslami et al., 2000), followed almost at the same time by air-conducted tone stimulation (Welgampola and Colebatch, 2001a), and more recently by lateral pulse stimulation at the mastoids (Todd et al., 2008). Air-conducted tone stimulation has been shown to produce responses of higher amplitude with a lower threshold than air-conducted click stimulation, and bone-conducted stimulation is advantageous in cases of conductive hearing loss as it bypasses the outer and middle ear. Forehead taps produce a wave of vibration that bypasses the middle ear as well, and directly activates the vestibular apparatuses on both sides simultaneously (Welgampola and Colebatch, 2001b). The precise afferents activated by skull taps are not known, although based on the appearance of lateral skull taps in normal subjects and in unilateral vestibulopathy, utricular stimulation has been proposed (Brantberg and Tribukait, 2002; Brantberg et al., 2003; Welgampola and Colebatch, 2005). However, bone-conducted sound, compared to the forehead tap, has the advantage of being a calibrated and reproducible stimulus and therefore elicits consistent responses and enables the measurement of stimulus thresholds (Welgampola et al., 2003). Lateral pulse stimulation is a more direction specific form of bone-conduction in the transmastoid plane, and is believed to be specific to utricular stimulation (Todd et al., 2008). The technique of galvanic stimulation may be well suited to investigating central disorders of vestibular function but the technical demands have limited the application of this stimulus to date. The wealth of stimulation types available as a result of intense research in the field may however have created confusion amongst clinicians. A reassessment of this information and a study of how they are all related was therefore needed in the field of vestibular electrophysiology. Several studies have been published in the past that compared the properties of the stimuli and the characteristics of the VEMP responses obtained (Welgampola and Colebatch, 2001b; Murofushi et al., 2002; Bacsi et al., 2003; Welgampola et al., 2003; Cheng et al., 2009). However, the different stimuli were still considered separately. This includes the more recent paper by Rosengren et al. (2011) even though it was detailed in its analysis. There are two aspects with respect to VEMP stimuli that a recent letter by Colebatch and his group has managed to address, and is the subject of this Editorial (Colebatch et al., 2013). One is the clarification with respect to the relationship between the different stimuli listed above. It required a further evaluation of the data published in the paper by Rosengren et al. (2011) to bring everything with regards to stimuli together. In this letter, a reassessment of all stimulus types was made with respect to age. Out of this analysis, it appeared that the stimuli were not something that would be compared to a recipe list after all. It instead revealed that the stimuli were in fact related to each other. Specifically, for both cVEMPs and oVEMPs, AC-clicks, AC tone burst and BC tone burst all decrease in amplitude with age, whereas cVEMPs and oVEMPs obtained with forehead taps and lateral pulse stimulation were all resistant to age effects. The second important piece of information that this reanalysis has provided is related to the otolith organ of origin of cVEMPs and oVEMPs. Although it is accepted by everyone that air-conducted click and tone stimulation stimulates the saccule to produce the cVEMP, this is not so straightforward for the oVEMP (Papathanasiou, 2012). The paper in this issue argues that the similarity in both responses (cVEMPs and oVEMPs) to click and tone (airand bone-conducted) stimuli is due to a common origin and based on earlier publications this would imply the saccule as the main otolith organ stimulated. The difference in the two groups of responses (correlating and not correlating with age) may be related to the frequency content of the stimulus and their ability to stimulate either the utricle or the saccule. An earlier study has shown that 100 Hz air-conducted tone stimulation may be selective for utricular stimulation (Zhang et al., 2011), in contrast to saccule stimulation where it is now known that 500 Hz is the best mode of air-conducted stimulation. Therefore, in relation to their frequency content, air-conducted click, tone and bone-conducted

Levetiracetam in three cases of progressive myoclonus epilepsy

We present three unrelated cases of genetically confirmed progressive myoclonic epilepsy of the Unverricht–Lundborg type who were treated with Levetiracetam as adjunctive therapy for their myoclonus. All cases responded with decrease of their myoclonus and improvement of quality of life. Two were able to return to or continue their employment. Patients tolerated the drug well without side effects reported. Levetiracetam appears to be a useful antimyoclonic agent in cases of progressive myoclonic epilepsy and should be considered for adjunctive therapy.

Photosensitivity During the Hypersomnic Phase in a Patient With Kleine-Levin Syndrome

The case of an adolescent with Kleine-Levin syndrome is presented who exhibited a consistent and predictable photoparoxysmal self-limited response to intermittent photic stimulation during all relapses of his hypersomnic phase. A possible cause of this association that has not been previously reported is speculated based on observations concerning the two disorders. (J Child Neurol 2003;18:432—433).

Radial nerve F-waves: normative values with surface recording from the extensor indicis muscle.

OBJECTIVES In the present study we set out to obtain normative values for radial nerve F-waves, with surface recording from the extensor indicis muscle. METHODS Forty-nine patients with unrelated complaints were tested. Surface recording electrodes were placed on the extensor indicis muscle. This was found by asking the patient to extend the second digit against resistance. The active surface recording electrode was placed over the most distal portion of the muscle, near the radial border of the ulnar bone near the wrist. Stimulation was performed near the lateral epicondyle between the radial and ulnar bones. RESULTS The mean F-wave minimum latency was found to be 20.55 ms, with an upper limit of 24.35 ms. The absolute interside minimum latency difference was found to have a mean of 0.55 ms, with a maximum of 1.7 ms. The mean amplitude of the F-waves was 145.61 microV and the mean mF/M ratio was 0.022. F-waves were unobtainable in 2/62 (3.2%) of limbs. Normative values for the radial nerve motor response were also obtained. Three cases are described to illustrate the usefulness of the above technique. CONCLUSIONS It is technically feasible to record radial nerve F-waves from the extensor indicis muscle.

Psychosocial adjustment of epilepsy patients in Cyprus

This study investigated aspects of psychosocial adjustment in epilepsy patients in Cyprus. Sixty-three patients under 55 years of age with idiopathic or symptomatic epilepsy and 89 neurologically matched healthy volunteers participated. Subjects completed the State and Trait Anxiety Inventory and the Beck Depression Inventory; patients with epilepsy also completed the Epilepsy Foundation Concerns Index. Results showed that patients with symptomatic epilepsy had significantly higher scores on state and trait anxiety and depressive symptoms. Sociodemographic characteristics including gender, marital status, and education levels contributed to differences in trait and state anxiety, depressive symptom scales, autonomy concerns, and fear for seizure recurrence. Variables such as poor seizure control and use of polytherapy were associated with lower adjustment scores and reduced psychosocial outcome. Finally, patients with epilepsy scored significantly higher on depression and anxiety symptoms. The results provide further evidence on challenges patients with epilepsy face and on the need for implementing psychosocial prevention programs.

Brainstem lesions may be important in the development of epilepsy in multiple sclerosis patients: an evoked potential study.

OBJECTIVE Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system, with epileptic seizures sometimes observed in the same patients. In this study, we used evoked responses to study the pathogenesis of epilepsy in MS. METHODS Patients with a diagnosis of definite MS and who had EPs performed (visual (VEP), brainstem auditory (BAEP) and short latency somatosensory (upper (USSEP) and lower (LSSEP))) were retrospectively included in this study. They were divided into three groups; Group I: Patients with no epilepsy and who were not taking anti-epileptic drugs (AED); Group II: Patients with epilepsy and taking AEDs; and Group III: Patients with no epilepsy who were taking AEDs for symptoms related to neuropathic pain. RESULTS Three hundred and fifty-five patients were included in this study; Group I: 229 patients (64.5%), Group II: 20 patients (5.6%) and Group III: 106 patients (29.9%). The proportion of patients with abnormal BAEP and USSEP was higher in Group II. CONCLUSIONS A positive association exists between the presence of epilepsy in MS patients and BAEP and USSEP abnormalities. Analysis of Group III ruled out AED use as a factor. SIGNIFICANCE Brainstem lesions may be the cause of epileptogenicity in MS.

Tuberous sclerosis successfully treated with levetiracetam monotherapy: 18 months of follow-up

CaseWe present the case of a boy with tuberous sclerosis who was referred for evaluation and treatment of his intractable epileptic seizures, having failed multiple anti-epileptic drug trials. He was subsequently treated with Levetiracetam that was gradually titrated to an effective dose, achieving full suppression of his seizures. Thereafter, his concomitant anti-epileptic drugs were gradually reduced and eventually discontinued. He remained on monotherapy with Levetiracetam, which continued to fully control his seizures. His EEG tracings before and after treatment are presented and compared, showing normalization of the latter.ConclusionLevetiracetam appears to be effective in treatment-resistant seizures which are symptomatic to tuberous sclerosis when used adjunctively as well as in monotherapy. This is the first report in the English literature regarding its use and efficacy in this condition.