OUTCOMES OF REFRACTORY STATUS EPILEPTICUS IN CHILDREN

Objective: To determine the outcome of Refractory Status Epilepticus (RSE) in children and the factors affecting the outcome. Study Design: Cross-sectional study. Place and Duration of Study: High Dependency Unit of Pediatrics Neurology Department at the Children’s Hospital and Institute of Child Health, from Aug 2019 to Mar 2020. Methodology: This study was conducted on the children presenting with refractory status epilepticus. Structured proforma was used for recording predictive factors. Modified Rankin scale prior to the presentation and Glasgow Coma Scale at presentation were documented and compared with the discharge scores. Results: Out of 75 children, 46 (61.4%) were males with mean age of 4.43 ± 3.47 years. Common etiologies were acute symptomatic in 37 (49.3%), progressive encephalopathy in 19 (25.3%), static encephalopathy in 9 (11.9%), remote symptomatic in 4 (5.3%), acute on remote symptomatic in 3 (4.0%), idiopathic and unclassified in remaining patients. Mean time between seizures onset and first benzodiazepine injection was 44 ± 36 minutes. Duration of RSE was <24 hours in 17 (22.7%), 24-48 hours in 15 (20.0%), 48-72 hours in 14 (18.6%), 72-96 hours in 12 (16%) and >96 hours in 17 (22.7%). At discharge 33 (44%) returned to baseline, 31 (41%) developed neurological disability while 11 (15%) expired during the stay. Etiology and duration of status epilepticus had significant impact on outcome with p-value of 0.021 and 0.041, respectively. Conclusion: Acute etiology was associated with higher mortality whereas return to baseline was also fair among survivors. This poses implications for emergency management to significantly............

Rationale of an Advanced Integrative Approach Applied to Autism Spectrum Disorder: Review, Discussion and Proposal

The rationale of an Advanced Integrative Model and an Advanced Integrative Approach is presented. In the context of Allopathic Medicine, this model introduces the evaluation, clinical exploration, diagnosis, and treatment of concomitant medical problems to the diagnosis of Autism Spectrum Disorder. These may be outside or inside the brain. The concepts of static or chronic, dynamic encephalopathy and condition for Autism Spectrum Disorder are defined in this model, which looks at the response to the treatments of concomitant medical problemsto the diagnosis of Autism Spectrum Disorder. (1) Background: Antecedents and rationale of an Advanced Integrative Model and of an Advanced Integrative Approach are presented; (2) Methods: Concomitant medical problems to the diagnosis of Autism Spectrum Disorder and a discussion of the known responses of their treatments are presented; (3) Results: Groups in Autism are defined and explained, related to the responses of the treatments of the concomitant medical problems to ASD and (4) Conclusions: The analysis in the framework of an Advanced Integrative Model of three groups including the concepts of static encephalopathy; chronic, dynamic encephalopathy and condition for Autism Spectrum Disorder explains findings in the field, previously not understood.

Recent advances in cerebral palsy

The words unpreventable, incurable, and untreatable are still synonymous with cerebral palsy (CP). However, research and evidence coming from the fields of neuroplasticity, neuroregeneration, and neuroprotection provide considerable cause for optimism for children with CP. There are now at least 64 different interventions for CP seeking 131 outcomes. A search of the Cochrane Library, PubMed, and Google Scholar was made using the keywords: CP, static encephalopathy, birth asphyxia, perinatal insult, hypoxic-ischemic encephalopathy, and neonatal encephalopathy. We found evidence to suggest that following interventions: Anticonvulsant drugs, ankle casting, botulinum toxin for focal spasticity, bisphosphonates, diazepam, hip surveillance, and dorsal rhizotomy are effective. The following interventions improve function: Bimanual training, constraint-induced movement therapy, context focused therapy, goal-directed/functional training, home programs, and occupational therapy. These interventions are effective if started early in life. Therapies such as hyperbaric oxygen, hip bracing, and neurodevelopmental therapy when child contractures are already developed are ineffective. In the last decade, the evidence on CP has rapidly expanded, providing clinicians and families with the possibility of newer, safer, and more effective interventions. In this update, the author reviews the current evidence of the management of CP and provides a comprehensive evaluation and multidisciplinary management.

SEAS Exercise to Treat Scoliosis and Improve Functional Activities in Children with Spastic Cerebral Palsy

SEAS exercise to improve functional activities among the children with spastic hemiplegic cerebral palsy children. Single group pre- post experimental research design. Cerebral paralysis is a static encephalopathy which affects the immature brain and leads to permanent motor disability. Due to a combination of spasticity, muscle weakness and incompletion of muscle control, the spinal deformity occurs in rising patients with CP; it can lead to poor balance in the trunk and significantly limits patient function. SEAS exercise capacity to enhance the self-corrected posture by concentrating during everyday activities. Eighty eight subjects of spastic hemiplegic cerebral palsied children, aged 6-12, male and female with scoliosis were selected under purposive sampling technique and received SEAS exercise training for a period of eight weeks. pre and post outcome measures were assessed using Modified Ashworth scale and Scoliometer to measure the functional activity in the children Pediatric balance scale, functional gait assessment and Gross motor function were used. Significant changes in spasticity and scoliosis were observed, and functional parameters were increased. The results of the post-test mean values for all SEAS variables demonstrated substantial improved balance, reduced scoliosis and gross motor functions in those receiving SEAS protocol (p<0.05). The SEAS exercise proves there was a decrease in scoliosis and their by improvement in functional abilities among children with spastic hemiplegic cerebral palsy after eight weeks of intervention.

P027: Who should discuss goals of care during acute deteriorations in patients with life threatening illnesses? A survey of clinicians from diverse pediatric specialties

Introduction: Discomfort exists discussing goals of care with families of children with advanced life-threatening illnesses. There also exists important variability in the management of these patients. This study seeks to explore the perceptions of pediatric specialists involved in the care of children with life-threatening illnesses with regards to goals of care discussions and management during acute unexpected deteriorations. Methods: This single center survey study used 4 scenarios of children presenting to the emergency department with respiratory distress. Scenarios included patients with hypoplastic left heart syndrome, static encephalopathy, spinal muscular atrophy and refractory leukemia. Questions following each vignette were identical. Physicians from the specialties most involved in these scenarios completed the survey by email or in person. Data analysis used SPSS v.20 (IBM Inc.). Related samples non-parametric tests compared participants’ Likert scale answers. Results: Between May 2015 and May 2016, 60 participants completed the study; 14 were excluded (&gt;60% missing answers). Most (80.4%) participants reported an interest in pediatric palliative care; 71.7% had 0-3 formal trainings. Participants believed goals of care were best discussed before an acute deterioration. Acute deteriorations were not seen as an opportune moment to initiate discussions about goals of care. However, validating these previous wishes was necessary, given that not discussing them was judged unacceptable by the participants. Pediatric specialists were seen as the most suitable teams to initiate these discussions, while the emergency department's role in these discussions was unclear. Several management options were less acceptable for the patient with static encephalopathy. Conclusion: Discussing goals of care during acute illness exacerbation involves many stakeholders, who may not always be available at critical times. Advanced care planning with these families is essential to prepare them for acute health events.

Spastic Quadriplegia

The diagnosis of spastic quadriplegia due to cerebral palsy should be made only after a detailed patient history. The patient should be assessed for prior history of prematurity, intraventricular hemorrhage, or static encephalopathy following a characteristic developmental progression of neurologic findings. MR imaging is used to assess brain anatomy, and the addition of metabolic and/or genetic testing for atypical cases should be considered. Proper patient selection for intrathecal baclofen placement can be confirmed by careful preoperative evaluation and a trial of intrathecal baclofen administered by lumbar puncture. Patients in the pediatric age range with significant medical comorbidities or with low BMI are at elevated risk of baclofen pump–related complications, which should be balanced against indications for pump placement.