Monday, September 25, 2017

Blog #86: What We All Knew Is Now Documented: Stress & Missed Sleep Trigger Seizures



            According to a report presented at the 69th Annual Meeting of the American Academy of Neurology, stress was found to be the most common trigger of seizures. Stress was linked to 37% of seizures in a study population. The research was led by Gregory Krauss, MD, Professor of Neurology at Johns Hopkins University and is summarized in the June 2017 issue of Neurology Reviews (www.neurologyreviews.com). Dr. Krauss and colleagues used an Apple Watch app called EpiWatch to track seizures over ten months. The app was created using Research-Kit, which was designed by Apple to aid researchers to gather this data.

            When the 598 participants perceived a seizure aura they would open the app. Then EpiWatch recorded heart rate and body movements for 10 minutes. The app asked the person to perform tasks to test responsiveness. The patient was asked to record seizure type, aura, loss of awareness and possible seizure triggers. The app also helped track medication use and drug side effects.

            Forty percent of the group tracked a total of 1,485 of their seizures. Information about the person’s opinion of a possible seizure-trigger was also tracked. The most common reported trigger was stress, linked to 37% of seizures. Participants also identified lack of sleep as a trigger for 18% of the seizures, menstruation for 12% and over-extension of their activities for 11%. Other reported triggers included diet (9%), missed medications (7%), and fever or infection (6%). Seizure triggers did not vary by the type of seizure.

            Those participants who worked full-time reported stress as the trigger in 35% of their seizures compared with 21% of seizures in part-time workers. The investigators found that unemployed people reported stress as a trigger in 27% and disabled people reported stress was a trigger in 29% of their seizures. Missed medication was a trigger in 40%, especially in younger people ages 16-25 years, while among older people ages 26-66, thirty-four percent reported missed medications as a trigger.

            The investigators hope to be able to use wearable technology to predict oncoming seizures.


Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Friday, August 25, 2017

Blog #85: More on Death in Epilepsy: What to Do




            Among the 84 blogs I have posted at LANCEFOGAN.COM since 2011, three (#13, #57 and #68) have focused on “sudden death in epilepsy” (SUDEP). Too often, physicians fail to discuss SUDEP with their epilepsy patients, their families, and their caregivers because physicians claim that they did not want to impose unnecessary fear. Other physicians argue that SUDEP disclosure could aid in improving medication compliance and improved health-life-style compliance. Below are suggestions to minimize SUDEP.

            The cause of SUDEP remains unknown. Patients with epilepsy are 24 times more likely to suddenly die compared with age-matched controls. SUDEP is responsible for 2 to 18% of epilepsy-related deaths and is the most common epilepsy-related cause of death in patients with poorly-controlled seizures. Eliminating, or at least minimizing, convulsions is the goal because that has been shown to reduce SUDEP risk. 1

            A total of 64 patients with long term epilepsy completed a survey that was presented by Lucretia Long, MS, RN, CNP, at the 69th Annual Meeting of the American Academy of Neurology. All participants felt it was their right to be informed about SUDEP. A third of patients admitted disclosure frightened them but they still believed it their right to be informed. SUDEP is most likely to affect those with night-time tonic-clonic seizures that are poorly controlled. These individuals believed that SUDEP disclosure would benefit them by encouraging them to be more medication-compliant. Additionally, disclosure would encourage them to avoid factors that lower seizure threshold (less sleep, alcohol and illicit drug use). 2

                Most SUDEP occurs in bed where the patient is sleeping. While medical support, even within 2 minutes following a convulsion, doesn’t always prevent SUDEP, evidence supports that death is less likely when someone can rapidly stimulate or reposition the patient. 3 Consider alert monitors such as devices like baby monitors that can transmit unusual sounds coming from the patient’s bedroom that would alert others to attend to the patient as soon as possible and conceivably save lives.

  1.  Dworetzky A. Gaining Perspective on SUDEP. The new guideline. Neurology 2016; 88: 1598-1599
  2. Williams GS. Neurology Reviews. June 2017, page 13. 
  3. Devinsky O, Hessdorfer DC, Thurman DJ, et. al. Sudden unexpected death in epilepsy: epidemiology, mechanisms, and prevention. Lancet Neurol 2016; 15: 1075-1088. 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Wednesday, July 26, 2017

Blog #84: A FAMILY DEALS WITH UNRECOGNIZED EPILEPSY

Excerpted from Dr. Lance Fogan’s novel, DINGS
Chapter 20 (continued): Part II



That evening I stood in the doorway of the kids’ bathroom and watched Sam tell Conner about the anti-seizure medication. “Conner, the doctor said that you need to take these Dilantin capsules or you could start shaking again.” Sam forced a hesitant smile, gauged Conner’s response and his expectant face, and continued, “So you need to swallow these capsules. You have to take one of these smaller ones with a drink of water every morning. Then, you have to take this bigger one—this one with the red stripe—every night before bed. We’re going to start with the bigger one.”
“No! It’s too big, Daddy. I won’t! I can’t swallow that!” A vein throbbed in Conner’s neck and his eyes brimmed with tears. He kicked the lower cabinet door under the sink. “I won’t do it!”
“Conner, stop that right now! I am not going to argue with you about this! You’re going to take this medicine,” Sam ordered. “Here’s a glass of water. Put the capsule in your mouth and swallow it with some water. It will go right down. Open up.”
It was difficult to watch them, but I didn’t butt in.
I saw Sam’s hand tremble as he placed the capsule on our son’s swollen and discolored tongue. Conner wrinkled his nose and took a sip of water from the glass. He immediately started to gag.
“Here! Swallow, Conner! Hold your head over the sink!” Sam’s attempt at self-control was pathetic. He was about to lose it.
Conner retched a couple times and spit the capsule out with the water. He sobbed, “I can’t swallow it! I’ll choke!”
Sam grimaced. “Come on, Conner,” he said as he retrieved the capsule from the sink. “You can do it. Try again.” The boy began to cry even harder and kicked the cupboard again. “Stop it! Stop kicking!”
He grabbed Conner’s arm. Sam’s face blazed with fury.
I unfolded my arms and moved forward. “Hold on, Sam! Sam! Stop!” Conner’s screams muffled my protestations.
“Ahhhowwww! You’re hurting me! Stop it, Daddy! Stop it! You’re hurting me!”
“Sam! Sam, enough! Let me try. You wait downstairs. Conner and I will get it down. Go ahead. I’ll be down in a minute.”
Sam dropped Conner’s arm and shook his head. “Okay. Yeah, I’ll go downstairs. I’m sorry, Conner.” He handed me the capsule, turned on a military heel and left.
Conner sobbed, “Owww. Daddy hurt my arm, Mom!”
“He didn’t mean to, honey. He didn’t mean it. Come on. I’ll help you take it.”
“I won’t t-take it! It’s n-not fair!” He screamed between sobs. “Why do I have to t-take that pill? It’s too big! I’ll ch-choke!”
“I know, Conner. It’s hard to do new things sometimes. But it’s very, very important that you swallow this pill.” At that moment the tune from Mary Poppins, “A Spoonful of Sugar,” sprang into mind. “Do you think that if I put it in some ice cream, or maybe chocolate milk, you’d be able to swallow it? I think it would be a lot easier. Let’s try that, okay?”
Conner’s demeanor immediately softened. I flashed him a smile. I should have asked Dr. Choy to give us a liquid form of the Dilantin if there was one. Conner would have to swallow this tonight, but if he couldn’t get it down I would call Dr. Choy.
He sobbed a couple of times and wiped tears with his pajama sleeve.
“Let’s go to the kitchen and put the capsule in some chocolate ice cream.” I took his hand and we went downstairs.
“Did he take it?” Sam called. He was sitting on the couch in the den, holding a glass half-filled with an amber liquid. An open whiskey bottle was on the coffee table. “I’m sorry that I grabbed you, son. Forgive me, Conner?”
“Yeah, Daddy, but you squeezed my arm real hard,” he answered as he wiped his nose with the sleeve of his free hand.
“He’s going to take it with chocolate ice cream.” I said with a grin and began to sing, “A-spoonful-of-sugar-la-da-da-da-da-da.” Conner sat in his usual seat at the kitchen table. He had a sheepish grin. I got the ice cream out of the freezer and scooped some into a bowl. Sam walked in, the newspaper clenched in one hand and the glass in the other.
I put a large spoonful into his mouth as he mumbled, “Whipped cream?”
“Whipped cream! What a great idea, Conner! Sure.” I took the can of whipped cream out of the refrigerator and shook it. “Here’s what we’ll do: swallow that chocolate spoonful, and then we put the Dilantin capsule on your tongue. You open wide, I’ll squirt the whipped cream into your mouth and you swallow it right down. Okay?”
A broad grin appeared and he nodded.
“Open wide.” I put the capsule on his tongue, tilted the can and depressed the nozzle. A white mass hissed and billowed as it squirted into his mouth. His cheeks puffed out. He swallowed.
“Open.” I peered in. “It worked!” I looked at Sam. We all laughed.
“Hey, can I try that?”
“Open up, Daddy,” I said, as I squirted the whipped cream into his mouth.
Conner squealed with laughter.
“That’s a great technique, guys. Ice cream and whipped cream whenever you need it, Conner.”
Conner beamed. “Yeah, Daddy, that way I can eat the medicine.”
“Okay, honey. You did great. Now, floss and brush and get into bed. Daddy will come up to tuck you in after me. Let’s go.”
I turned and glared at the glass in my husband’s hand. “Put that away.” I mouthed the words and followed Conner upstairs.




Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Tuesday, June 27, 2017

Blog # 83: A FAMILY DEALS WITH UNRECOGNIZED EPILEPSY Excerpted from Dr. Lance Fogan’s novel, DINGS Chapter 20: Part I



Chapter 20: Part I

Conner was still asleep at noon. Madison sat at the kitchen table with us and gulped chocolate milk from her sippy cup.
Sam held up half of a peanut-butter-and-jelly sandwich for her to bite. She asked, “Where did we go yethterday, Daddy?”
As he started to explain, I jumped up to answer the phone. “Oh, thank you for calling back, Dr. Jackson. I want to tell you what happened to Conner last night…”
After I hung up I said to Madison, “Hey, kiddo, how about watching a Barney DVD?”
The toddler grinned and clapped her hands. “Yay!”
“Would you pour some coffee, honey? I’ll get her started on the DVD, and then I’ll tell you what Dr. Jackson said.” I returned to the kitchen a few minutes later. In a low voice, I said, “The pediatrician was very complimentary of Dr. Choy. Apparently, Dr. Jackson works with him a lot. And with Dr. O’Rourke, that neurologist Conner’s going to see. Anyway, he agreed that we should continue to give Conner the Dilantin since Dr. Choy had already started it. But, he said that the neurologist might change the medication, or even stop it—please, God.”
I sat down and poured cream into my coffee. I smiled and watched the steam rise and swirl above my blue-and-white mug. The edges of my lips took a cautious, noisy sip. “Just like Dr. Choy said, Dr. Jackson thinks that we should tell Conner’s teachers what happened. You know, so they’ll be aware of, well—in case anything happens at school.”
Sam nodded. “So, Dr. Jackson thinks it could happen again, too, even though all of Dr. Choy’s tests were normal and he’s on the medicine?”
“Well, no! I mean, it shouldn’t.” I put my cup down too hard and some coffee sloshed onto the table. I stared at the spilled drops and then pushed them together with my finger. “That medicine, the Dilantin, should prevent any more of those seizures, he said.”
“But, Sandra, until we see the specialist—until we know exactly what’s going on—I mean, could Conner have another convulsion?”
My eyes bored into his. “Yessss.”
“Mommy! Mommy! I’m hungry!”
We sprang from our chairs. I called into the den, “Madison, we’ll be right back, honey!”
Sam took the stairs two steps at a time in front of me.
Conner was sitting up in bed when we got to his room. “It’s so late, Mom. What about school? My tongue hurts real bad. I hurt all over! And, I got a bandage on my arm, and there’s one on my back, too! How’d they get there?”
Sam and I exchanged a quick glance. Sam sat on Conner’s bed. I knelt on the floor and wrapped both arms around my son. I closed my eyes and squeezed him. I did not know how to tell him about his convulsion, or even if I should tell him. No, of course, he needed to know. Still short of breath after the rush up the stairs, I asked, “Do you remember what happened last night, honey?” Conner shook his head.
“You remember how bad your cough was last night, and your nose was all runny? Do you remember?”
“Yeah…”
“Well, you got a real high fever and your cold made you shake all over. It made you bite your tongue, too. That’s why it hurts, honey. Here, let’s see it.” I stuck mine out reflexively.
His swollen tongue—pink, but for a bluish, ragged gash along its left side—jutted out between his teeth. “Ooooh! It hurts.”
“I know it does. But, the doctor said it’ll get better in a day or two, honey.”
“Doctor? I was shaking? Why? What doctor said?”
“Daddy and I took you to the hospital last night because you were shaking. You stopped after a couple of minutes.” I looked at Sam. He nodded. “You had a brain scan—a CT scan the doctor called it—and some other tests.”
“Oh. I don’t remember. A brain scan! I had a brain scan, Mommy? Oh, boy! Wait ’til I tell the other kids. I know about them from TV! I remember that doctor guy, Beth’s father that came to my class and showed us pictures. Can I have breakfast?”
“Of course you can, and you can stay home from school today, too.” I laughed and squeezed him tighter. “How’s about chocolate-chip pancakes with lots of syrup and some chocolate milk?”
“Yeah! Let’s go!”
I remembered the headache Dr. Choy said could happen after the spinal tap. “How do you feel honey? Does your head hurt?”
“I feel achy, Mom. My cough is better, isn’t it?”
“Yes, it is, honey. Does your head hurt?”
“No. My tongue hurts. Can I have those pancakes and chocolate milk?”

***

         The second half of Chapter 20 of DINGS will appear in a future blog.


Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.