Pick Your Poison but Pick It Wisely: Choosing a Second-Line Medication for the Management of Status Epilepticus.
Ontology highlight
ABSTRACT:
SUBMITTER: Bermeo-Ovalle A
PROVIDER: S-EPMC7653661 | biostudies-literature |
REPOSITORIES: biostudies-literature
Similar Datasets
Project description:Introduction: Pediatric convulsive status epilepticus (CSE) which is refractory to first-line benzodiazepines is a significant clinical challenge, especially within resource-limited countries. Parenteral phenobarbital is widely used in Africa as second-line agent for pediatric CSE, however evidence to support its use is limited. Purpose: This study aimed to compare the use of parenteral phenobarbital against parenteral phenytoin as a second-line agent in the management of pediatric CSE. Methodology: An open-labeled single-center randomized parallel clinical trial was undertaken which included all children (between ages of 1 month and 15 years) who presented with CSE. Children were allocated to receive either parenteral phenobarbital or parenteral phenytoin if they did not respond to first-line benzodiazepines. An intention-to-treat analysis was performed with the investigators blinded to the treatment arms. The primary outcome measure was the success of terminating CSE. Secondary outcomes included the need for admission to the pediatric intensive care unit (PICU) and breakthrough seizures during the admission. In addition, local epidemiological data was collected on the burden of pediatric CSE. Results: Between 2015 and 2018, 193 episodes of CSE from 111 children were enrolled in the study of which 144 met the study requirements. Forty-two percent had a prior history of epilepsy mostly from structural brain pathology (53%). The most common presentation was generalized CSE (65%) caused by acute injuries or infections of the central nervous system (59%), with 19% of children having febrile status epilepticus. Thirty-five percent of children required second-line management. More patients who received parenteral phenobarbital were at a significantly reduced risk of failing second-line treatment compared to those who received parenteral phenytoin (RR = 0.3, p = 0.0003). Phenobarbital also terminated refractory CSE faster (p < 0.0001). Furthermore, patients who received parenteral phenobarbital were less likely to need admission to the PICU. There was no difference between the two groups in the number of breakthrough seizures that occurred during admission. Conclusion: Overall this study supports anecdotal evidence that phenobarbital is a safe and effective second-line treatment for the management of pediatric CSE. These results advocate for parenteral phenobarbital to remain available to health care providers managing pediatric CSE in resource-limited settings. Attachments: CONSORT 2010 checklist Trial registration: NCT03650270 Full trial protocol available: https://clinicaltrials.gov/ct2/show/NCT03650270?recrs=e&type=Intr&cond=Status+Epilepticus&age=0&rank=1.
| S-EPMC6530138 | biostudies-literature
Project description:We surveyed internal medicine residents regarding how they approach febrile patients in cross-cover settings. Residents frequently use the term "full fever work-up," and rely on this for sign-out. Despite this, residents felt fever work-ups were not evidenced-based, and definitions of when and how to respond to a fever varied.
| S-EPMC5473033 | biostudies-literature
Project description:Status epilepticus is a common pediatric neurological emergency. Management includes prompt administration of appropriately selected anti-seizure medications, identification and treatment of seizure precipitant(s), as well as identification and management of associated systemic complications. This review discusses the definitions, classification, epidemiology and management of status epilepticus and refractory status epilepticus in children.
| S-EPMC4850470 | biostudies-other
Project description:Identifying the tests/procedures ordered by neurologists that contribute most to health care expenditures is a critical step in the process of creating the neurology top 5 list for the Choosing Wisely initiative. Using data from the 2007-2010 National Ambulatory Care Medical Survey, we found that $13.3 billion (95% confidence interval = $10.1-$16.5 billion) was spent on tests ordered at neurologist visits. The tests/procedures with the highest expenditures were magnetic resonance imaging (MRI; 51% of total expenditures; $7.5 billion), electromyography (EMG; 20% of expenditures; $2.6 billion), and electroencephalography (EEG; 8% of expenditures; $1.1 billion). MRI, EMG, and EEG should receive close scrutiny in the development of the neurology top 5 list.
| S-EPMC5570467 | biostudies-literature
Project description:Despite the growing enthusiasm surrounding the Choosing Wisely® campaign, little is known regarding the evidence underlying these recommendations. We extracted references for all 320 recommendations published through August, 2014, including the 10 adult and pediatric recommendations published by the Society for Hospital Medicine. We then categorized each item by evidence strength, and then assessed a sample of referenced clinical practice guidelines (CPGs) using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Among all recommendations, 70.3% cited CPGs, whereas 22.2% cited primary research as their highest level of evidence. Moreover, 7.8% cited case series, review articles, editorials, or lower quality data as their highest level of evidence. Hospital medicine recommendations were more likely to cite CPGs (90%) as their highest level of evidence. Among the sampled CPGs, the median overall score obtained using AGREE II was 54.2% (IQR 33.3%-70.8%), whereas among hospital medicine-referenced CPGs, the median overall score was 58.3% (IQR 50.0%-83.3%). These findings suggest that Choosing Wisely® recommendations vary in terms of evidence strength.
| S-EPMC6204196 | biostudies-literature
Project description:BackgroundPhenytoin is the recommended second-line intravenous anticonvulsant for treatment of paediatric convulsive status epilepticus in the UK; however, some evidence suggests that levetiracetam could be an effective and safer alternative. This trial compared the efficacy and safety of phenytoin and levetiracetam for second-line management of paediatric convulsive status epilepticus.MethodsThis open-label, randomised clinical trial was undertaken at 30 UK emergency departments at secondary and tertiary care centres. Participants aged 6 months to under 18 years, with convulsive status epilepticus requiring second-line treatment, were randomly assigned (1:1) using a computer-generated randomisation schedule to receive levetiracetam (40 mg/kg over 5 min) or phenytoin (20 mg/kg over at least 20 min), stratified by centre. The primary outcome was time from randomisation to cessation of convulsive status epilepticus, analysed in the modified intention-to-treat population (excluding those who did not require second-line treatment after randomisation and those who did not provide consent). This trial is registered with ISRCTN, number ISRCTN22567894.FindingsBetween July 17, 2015, and April 7, 2018, 1432 patients were assessed for eligibility. After exclusion of ineligible patients, 404 patients were randomly assigned. After exclusion of those who did not require second-line treatment and those who did not consent, 286 randomised participants were treated and had available data: 152 allocated to levetiracetam, and 134 to phenytoin. Convulsive status epilepticus was terminated in 106 (70%) children in the levetiracetam group and in 86 (64%) in the phenytoin group. Median time from randomisation to cessation of convulsive status epilepticus was 35 min (IQR 20 to not assessable) in the levetiracetam group and 45 min (24 to not assessable) in the phenytoin group (hazard ratio 1·20, 95% CI 0·91-1·60; p=0·20). One participant who received levetiracetam followed by phenytoin died as a result of catastrophic cerebral oedema unrelated to either treatment. One participant who received phenytoin had serious adverse reactions related to study treatment (hypotension considered to be immediately life-threatening [a serious adverse reaction] and increased focal seizures and decreased consciousness considered to be medically significant [a suspected unexpected serious adverse reaction]).InterpretationAlthough levetiracetam was not significantly superior to phenytoin, the results, together with previously reported safety profiles and comparative ease of administration of levetiracetam, suggest it could be an appropriate alternative to phenytoin as the first-choice, second-line anticonvulsant in the treatment of paediatric convulsive status epilepticus.FundingNational Institute for Health Research Health Technology Assessment programme.
| S-EPMC6551349 | biostudies-literature
Project description:Objective: Status epilepticus is a major emergency condition. The choice of antiepileptic drugs for second-line treatment after benzodiazepine remains controversial, including levetiracetam vs. fosphenytoin. We compare the safety of intravenous levetiracetam and fosphenytoin as a second-line treatment in patients with status epilepticus using a nationwide database. Methods: An observational study conducted with the Japanese Diagnosis Procedure Combination inpatient database identified adult patients who had been admitted for status epilepticus and who had received intravenous diazepam on the day of admission from March 1, 2011 to March 31, 2018. Patients who received intravenous levetiracetam on the day of admission were defined as the levetiracetam group and those who received intravenous fosphenytoin on the day of admission were defined as the fosphenytoin group. Propensity score matching was performed to compare outcomes obtained for the levetiracetam and fosphenytoin groups. Results: The analysis examined data of 5,667 patients. Overall, 1,403 (25%) patients received levetiracetam; 4,264 (75%) received fosphenytoin. One-to-one propensity score matching created 1,363 matched pairs. No significant difference was found in in-hospital mortality (5.2 vs. 5.1%; odds ratio, 1.03; 95% confidence interval, 0.73-1.46). The proportion of vasopressor use on the day of admission was significantly lower for the levetiracetam group than for the fosphenytoin group (3.2 vs. 4.9%; odds ratio, 0.63; 95% confidence interval, 0.43-0.92). No significant difference was found in other secondary outcomes including total hospitalization cost. Conclusion: Levetiracetam was related to significantly reduced vasopressor use on the day of admission than that found for fosphenytoin, in adult status epilepticus.
| S-EPMC7348044 | biostudies-literature
Project description:ObjectivesEvidence suggests that approximately 30% of the tests and treatments currently prescribed in healthcare are potentially unnecessary, may not add value, and in some cases cause harm. We describe the evolution of our hospital's Choosing Wisely (CW) program over the first 5 years of existence, highlighting the enablers, challenges, and overall lessons learned with the goal of informing other healthcare providers about implementing resource stewardship initiatives in paediatric healthcare settings.MethodsWe describe the development of de novo "top 5" CW lists of recommendations using anonymous surveys and Likert scale scoring. Composition and role of the steering committee, measurement of data and outcomes, and implementation strategies are outlined.ResultsMany projects have resulted in a successful decrease in inappropriate utilization while simultaneously monitoring for unintended consequences. Examples include respiratory viral testing in the emergency department (ED) decreased by greater than 80%; ankle radiographs for children with ankle injuries decreased from 88% to 54%; and use of IVIG for treatment of typical ITP cases decreased from 88% to 55%. Early involvement focused within General Paediatrics and the ED, but later expanded to include perioperative services and paediatric subspecialties.ConclusionsAn internally developed CW program in a children's hospital can reduce targeted areas of potentially unnecessary tests and treatments. Enablers include credible clinician champions, organizational leadership support, reliable measurement strategies, and dedicated resource stewardship education. The lessons learned may be generalizable to other paediatric healthcare settings and providers looking to introduce a similar approach to target unnecessary care in their own organizations.
| S-EPMC10186090 | biostudies-literature
Project description:OBJECTIVES:To determine whether utilization of clinical decision support (CDS) is correlated with improved patient clinical and financial outcomes. STUDY DESIGN:Observational study of 26,424 patient encounters. In the treatment group, the provider adhered to all CDS recommendations. In the control group, the provider did not adhere to CDS recommendations. METHODS:An observational study of provider adherence to a CDS system was conducted using inpatient encounters spanning 3 years. Data comprised alert status (adherence), provider type (resident, attending), patient demographics, clinical outcomes, Medicare status, and diagnosis information. We assessed the associations between alert adherence and 4 outcome measures: encounter length of stay, odds of 30-day readmission, odds of complications of care, and total direct costs. The associations between alert adherence and the outcome measures were estimated using 4 generalized linear models that adjusted for potential confounders, such as illness severity and case complexity. RESULTS:The total encounter cost increased 7.3% (95% CI, 3.5%-11%) for nonadherent encounters versus adherent encounters. We found a 6.2% (95% CI, 3.0%-9.4%) increase in length of stay for nonadherent versus adherent encounters. The odds ratio for readmission within 30 days increased by 1.14 (95% CI, 0.998-1.31) for nonadherent versus adherent encounters. The odds ratio for complications increased by 1.29 (95% CI, 1.04-1.61) for nonadherent versus adherent encounters. CONCLUSIONS:Consistent improvements in measured outcomes were seen in the treatment group versus the control group. We recommend that provider organizations consider the introduction of real-time CDS to support adherence to evidence-based guidelines, but because we cannot determine the cause of the associations between CDS interventions and improved clinical and financial outcomes, further study is required.
| S-EPMC6813785 | biostudies-other
Project description:This guideline addresses the emergency management of convulsive status epilepticus (CSE) in children and infants older than 1 month of age. It replaces a previous position statement from 2011, and includes a new treatment algorithm and table of recommended medications based on new evidence and reflecting the evolution of clinical practice over the past several years. This statement emphasizes the importance of timely pharmacological management of CSE, and includes some guidance for diagnostic approach and supportive care.
| S-EPMC7850284 | biostudies-literature