Background: Status epilepticus (SE) is a neurological emergency requiring prompt evaluation and management to prevent disease refractoriness associated with significant mortality and morbidity. Thus, estimating costs attributable to the treatment of SE is important because of the severity of this disease. In the Philippines, healthcare provisions are mostly out-of-pocket expenses; hence the cost of treatment is a critical determinant for disease management. Unfortunately, the availability of data regarding the cost of illness of SE in developing countries is limited. Objectives: To determine the frequently used anticonvulsant drug regimen and direct inpatient costs of acute treatment for status epilepticus within five years in a private tertiary hospital in the Philippines. Methods: Records from patients diagnosed with SE who were admitted under or referred to the Adult Neurology Service in a private tertiary hospital from January 2015 to December 2019 were retrospectively evaluated. The SE type was classified as non-refractory (NRSE), refractory (RSE), and super refractory (SRSE). Demographic data, clinical features, SE type, etiology, antiepileptic drugs (AEDs) and anesthetic drugs used, total cost of AEDs and anesthetic drugs, total cost of 5-day hospitalization, and total cost of entire length of stay were recorded. Results: We retrieved the records of 61 patients admitted for SE. Of these patients, 23 were classified as nonrefractory, 20 as refractory, and 18 as super refractory. Diazepam was given to all SE patients as first-line treatment. Valproic acid and levetiracetam were used as second-line treatments. The most frequently given anesthetic drug was midazolam. The mean hospitalization cost per patient was ₱52,0982.3 for SE, ₱659,638.7 for RSE, and ₱134,1451 for SRSE. The mean cost of 5-day hospitalization was ₱193,572.3 for NRSE, ₱358,808.5 for RSE, and ₱652,781 for SRSE. The mean cost of medications was ₱18,546 for NRSE, ₱30,780 for RSE, and ₱128,263 for SRSE. Conclusion The direct cost of SE varied depending on subtype and response to treatment. Costs increased with disease refractoriness. Direct inpatient treatment costs for SRSE were twice as high as that of NRSE and RSE.
epilepsy ; status epilepticus ; hospitalization

Introduction. Migraine is a common, debilitating primary headache. Memantine is a non-competitive N-methyl D-aspartate (NMDA) antagonist that lowers neuronal excitability that could prevent migraine attacks. This study aimed to determine the efficacy and safety of memantine in patients with episodic migraine attacks using a systematic review and meta-analysis.

Methods. We searched CENTRAL, MEDLINE, Scopus, Cochrane, LILACS, ClinicalTrials.gov, HERDIN and Google Scholar for relevant studies until July 31, 2020. Prespecified screening and eligibility criteria for inclusion were applied. Included studies underwent methodological quality assessment. Study design, patient characteristics, interventions given, and relevant outcomes were extracted and synthesized.

Results. This review included five relevant articles - two randomized controlled trials (RCT) and three non randomized studies (one retrospective records review and survey, two prospective open-label single-arm trials). There were 109 patients included in the RCTs and 197 patients reported in the non-randomized studies. Pooled data from the two RCTs showed that memantine at 10 mg/day significantly decreased the monthly number of migraine days at 12 weeks compared to placebo with a mean difference of -1.58 [95% confidence interval (CI) -1.84, -1.32]. Non-randomized studies also showed a decrease in migraine days per month with memantine (5 to 20 mg/day) after 12 weeks [95% CI]: -9.1 [-11, -7.23], -7.2 [-8.85, -5.55], and -4.9 [-6.29, -3.51]. Adverse drug events (ADE) did not differ significantly between patients treated with memantine compared to placebo.

Conclusion. Memantine may be effective and well-tolerated as prophylaxis for episodic migraine.

Memantine ; Episodic migraine ; Systematic Review ; Meta-Analysis

Coronary heart disease, which includes acute coronary syndromes (ACS) is a major cause of death and morbidity. Treatment for this condition includes dual anti-platelet treatment combined with an anti-coagulant and an anti-dyslipidemic. Bleeding complications may occur and one fatal adverse event is intracerebral hemorrhage (ICH). ACS cases in a tertiary hospital for the years 2014-2018 showed that there were 7 patients who presented with symptomatic ICH after treatment administration that accounts for 0.01% of a total of 1,097 patients. These patients were over the age of 50, but with no sex predilection. Common comorbidities were hypertension and malignancy. All patients presented with acute onset neurologic deficits within 1-4 days after administration of ACS regimen, with ICH scores of 3-4 signifying a high mortality rate of 72-90%. 6 out 7 patients had significant volume of ICH with mass effects, and 1 with subarachnoid hemorrhage. This lead to poor outcome in all patients with 6 out of 7 mortalities and 1 left with substantial disability. It was found that given the total number of patients administered with the said treatment, there is a low incidence of ICH.
Myocardial Infarction

OBJECTIVE: To describe the profile, management, and outcome of adult patients admitted for tetanus. METHODOLOGY: A search of the hospital and department database was conducted for patients with admitting or final diagnosis of tetanus. Patients below 19 years old, with alternative diagnosis, incomplete or unavailable records, transferred to another institution, and went home against medical advice were excluded. Data on patient demographics, source of infection, symptom severity, and management were obtained. Data was described using proportions and averages. RESULTS: Thirty-two patients were included in the study. Twenty-seven were male with a mean age of 45.63 ± 13.39. All cases had no history of tetanus vaccination. The most common focus of infection was acute injuries. More than half of patients would be diagnosed within 72 hours of symptom onset. The most common symptoms on presentation were trismus, rigidity, dysphagia, and spasms. On admission, Cole severity for 11 (34.4%) cases was mild, 17 (53.1%) moderate, and 4 (12.5%) severe. Prophylactic tracheostomy was performed in 31 patients and 19 (59.4%) were placed on assisted ventilation. All cases were treated with metronidazole. A benzodiazepine was started in all cases for spasm control. Baclofen, magnesium sulfate, and antiepileptic drugs such as carbamazepine were also used. Twenty (62.5%) patients suffered from complications, the most common of which was nosocomial pneumonia, which resulted in longer ICU and hospital stays. Eleven patients exhibited progression in Cole severity: 8.6% at stage 1, 57.1% at stage 2, and 34.3% cases were at stage 3. Mortality rate was 19% with the proportion increasing with Cole severity. CONCLUSION We describe the presentation and course of patients admitted for tetanus in our institution. Most cases were males and all cases had no vaccination history. Trismus was the most common presenting symptom. Metronidazole was the antibiotic of choice and benzodiazepines were the mainstay for spasm control. Majority of cases were mild to moderate in severity on presentation. Advanced disease stages were associated with higher fatality rates. Complications were associated with longer ICU and hospital stay. These findings suggest that prevention of progression of disease severity and complications must be the focus of tetanus protocols to shorten hospital stay and decrease mortality rate. Promoting vaccination of at-risk adults is recommended to lower the incidence of tetanus.
Tetanus ; Clostridium tetani ; Clostridium Infections

BACKGROUND

Stroke is the second leading cause of death and the leading cause of disability in the Philippines. Despite the availability of clinical practice guidelines, there exist variation in the management pattern among neurologists.

OBJECTIVE

To determine the current practice patterns of Filipino adult neurologists caring for stroke patients and their conformity with the current clinical guidelines of the Stroke Society of the Philippines (SSP). Results are compared to a previous similar survey done in 2002 to determine changes in practice trends.

METHODOLOGY

Cross-sectional survey using a 3 page, 23-item questionnaire reviewed by the Stroke Council of the Philippine Neurological Asssociation (PNA).

RESULTS

From November 2007 to October 2008, 1 76 of 217 1ocally practicing board-certified adult neurologists of the Philippine Neurological Association (PNA) answered the survey achieving an 81.1% response rate. The following were the important findings: 1) 76.9% underestimated the benefit of warfarin for nonvalvular atrial fibrillation (NVAF); 2) despite the average 22 stroke patients seen in a week, 67% have used oral anticoagulation to no more than 8 patients during the past 6 months; 3) the two most important reasons provided for not giving oral anticoagulation were uncertainty of good follow-up from the patient and fear of bleeding complications; 4) for acute infarcts, although the recommended systolic blood pressure (SBP) threshold is ≥220mmHg, 65.3% would start antihypertensive treatment at 1 80mmHg; 5) ) for acute primary intracerebral hemorrhage (ICH), although SBP threshold is >180 mmHG, 89.6% would start antihypertensive treatment at 1 60mmHg; 6) despite the absence of guidelines recommending neuroprotective drugs for acute stroke, 75.6% and 48.0% prescribed it to >80% of their patients with infarcts and ICH respectively; 7) 54.3% have not experienced giving thrombolytic therapy to any of their patients with acute ischemic stroke; 8) among patients with clinically stable hemorrhagic strokes, 81 .4% of the neurologists would start antithrombotics and 35% of them would start it at 30 days after the onset of stroke; 9) among patients with ischemic stroke and atrial fibrillation who developed hemorrhagic transformation, 25.1% of respondents would start anticoagulation at 30 days post stroke; 1 0) length of neurology practice was significantly associated with the following variables (PCONCLUSIONS

The following practice patterns of Filipino neurologists in relation to the SSP guidelines are noted: underutilization of warfarin among patients with NVAF, preference to start pharmacologic control of BP below the recommended systolic levels especially in ischemic stroke, extensive use of neuroprotective agents and limited experience with thrombolytic use. Compared to the survey done in 2002, the general trends in stroke management remained unchanged though more in conformity to existing stroke guidelines.

Stroke ; Clinical Practice Variations ; Survey ; Atrial Fibrillation ; Neuprotection

INTRODUCTION: Stroke research in western countries has recently begun to focus on gender differences. There is evidence that the burden of stroke seems to be greater among women. They were found to have different stroke risk factor profiles from men; and found to be managed differently from men. To date, there are no local studies documenting gender disparities in stroke.

OBJECTIVES: To determine whether there are differences in stroke risk profiles -hypertension, diabetes mellitus, congestive heart failure, atrial fibrillation, previous strokes or transient ischemic attacks, smoking, BMI, low-density lipoprotein (LPL) levels, medication intake; stroke types; and initial stroke assessment  - NHSS scores and blood pressure levels on admission - among male and female stroke patients in our institution.

METHOD: Chart review of 181 stroke patients (98 males, 83 females) admitted in our institution over an eight-month period.

CONCLUSION: Our findings suggest that gender disparities among Filipino stroke patients may exist and should not be overlooked. Defining these disparities would then pave the way to optimal stroke risk management in our setting.

Human ; Male ; Female ; Aged 80 And Over ; Aged (a Person 65 Through 79 Years Of Age) ; Middle Aged (a Person 45-64 Years Of Age) ; Adult (a Perso ; Gender Identity ; Stroke ; Risk Factors ; Male ; Female ; Philippines ; Patients

INTRODUCTION: Intravenous administration of Recombinant Tissue Plasminogen Activator (IV-rTPA) has been an essential component of reperfusion treatment strategies in the aftermath of the 1995 National Institute of Neurological Disorders and Stroke (NINDS) TPA Stroke Study. However, it remains to be under-utilized both nationally and worldwide. Local data on thrombolytic use are very limited.

OBJECTIVES: This study aims to document our institution's experience with the use of intravenous thrombolysis in acute ischemic stroke cases by describing the demographic, clinical, radiographic, and management profiles of all our patients who were given IV - rTPA and their functional outcomes upon discharge and after three months.

METHOD: This is a descriptive study utilizing a clinical series design. Chart review of eighteen (18) patients who were admitted in our institution--a tertiary private hospital--due to acute ischemic stroke from January 2007 to August 2009 and who has given IV- rTPA was done. The patients' functional outcomes measured by the Modified Rankin Scale (MRS) upon discharge and at three months after stroke onset were documented by reviewing the patients' inpatient and outpatient records and by telephone interview conducted with the patients and/or their relatives.

RESULTS: The mean age of patients thrombolysed in our institution was 57.11 + 13.5 years (range: 31 to 80 years). All cases, except for one vertebrobasilar stroke, were anterior circulation strokes. Mean ictus-to-needle time frame for all thrombolysed patients was 174.3 + 56.6 minutes. The mean rTPA dose given to our patients was 0.87 + 0.08 mg/kg. A total 77.8% patients (14 of 18) received the standard rTPA dose of 0/9 mg/kg. Fourteen patients had follow-up imaging post-rTPA. Among these, 21.4% (3 of 14) developed non-symptomatic intracerebral hemorrhage (NSICH); 7.1% (1 of 14) developed a fatal symptomatic intracerebral hemorrhage (SICH). The mean baseline National Institutes of Health Stroke Scale (NIHSS) score of all patients was 14.9 + 5.9 (range: 4 to 24). Mean NIHSS score within the first 24 hours post-rTPA was 8.8 ± 6.1 (range: 0 to 19)--a 41% improvement from baseline. Eleven patients (11 of 18) or 61.1% were noted to have early improvement or an improvement of NIHSS score within the first 24 hours by ≥ 4. The mean follow-up NIHSS score beyond the first 24 hours post-rTPA was 5.5 ± 5.3 (range: 0 to 18), obtained at an average of 4.8 ± 2.4 days post-thrombolysis--a 63% improvement from the baseline mean NIHSS score. The mean MRS score of all patients upon hospital discharge was 3.17 ± 1.69. Two patients (2 of 18) or 11.1% expired 4 and 5 days post-thrombolysis; two (2 of 18) were lost to follow-up. For those who survived to discharge and not lost to follow-up (n=14), the mean MRS score at three months was noted to be 1.50 ± 1.09--a 53% improvement from mean MRS upon discharge. Seven of 18 patients (39%) had a favorable outcome defined as MRS ≤ 1 at three months post thrombolysis. Protocol deviations in our hospital were reported in 16.7% (3 of 18).

CONCLUSION: Our study showed trends to early improvement and favorable outcomes among stroke patients given IV-rTPA within 3 to 4.5 hours from ictus in our institution--with NIHSS scores improving by 40 to 60% during the course of their hospital stay, and 39% of patients having minimal or no disability at 3 months using the MRS. Our institution has more experience the standard rTPA dose of 0.9 mg/kg. A hospital brain rack team (BAT) that is on-call 24 hours' aids in the facilitation of thrombolytic treatment in acute ischemic strokes.

Human ; Aged 80 And Over ; Tissue Plasminogen Activator ; National Institute Of Neurological Disorders And Stroke (u.s.) ; Stroke ; Length Of Stay ; Brain Ischemia ; Inpatients ; Outpatients ; Follow-up Studies ; Lost To Follow-up ; Fibrinolytic Agents ; Cerebral Hemorrhage ; Reperfusion ; Administration, Intravenous ; Brain ; Hospitals, Private ; Demography ; Telephone

BACKGROUND AND OBJECTIVE: Upon accepting the invitation to participate in the 2003 National Nutrition Health Survey (NNHeS), the Philippine Neurological Association (PNA), through its research committee, decided to create and validate a questionnaire to determine the prevalences for stroke, Parkinsonism, dementia, migraine and epilepsy. This first of a two-part paper describes the validation of the 10 item PNA questionnaire.

METHODOLOGY: The five participating PNA councils contributed two questions that they believed were best able to capture the presence of the particular disease of their interest. These questions taken together formed the ten-item PNA questionnaire. Trained interviewers administered the questionnaire in neurology out-patient clinics on consecutive patients who agreed to join the study. Using neurologists' clinical diagnosis as gold standard after a face-to-face interview with the patient, the sensitivity and specificity of each item of the questionnaire were calculated.

RESULTS: The sensitivity and specificity of each item of the questionnaire showed modest results. This result is understandable for neurological syndromes with different clinical presentations having different subtypes and severity.

IMPLICATIONS: The validated PNA questionnaire was submitted to become part of the NNHeS survey. (Author)

Stroke ; Dementia ; Migraine Disorders ; Parkinsonian Disorders ; Epilepsy ; Prevalence

BACKGROUND AND OBJECTIVE: To date, there are no national prevalence data on common neurological conditions. This study aims to determine the prevalences of stroke, parkinsonism, dementia and migraine in the Philippines derived from a population-based sampling.

METHODOLOGY: Cross-sectional study using a multistaged cluster sampling methodology was employed. The validated PNA questionnaire was incorporated into the National Nutrition Health Survey (NNHeS) together with the survey tools of the other thirteen medical societies in need of their prevalence data.

RESULTS: This study evaluated 4,753 adults aged 20 or more from 2636 households, 17 regions and 79 provinces of the Philippines. The weighted adjusted point prevalence for stroke was 1.4 percent based on a previous diagnosis of stroke. Using the PNA questionnaire, the prevalence of parkinsonism, dementia and migraine were 0.95 percent, 3.14 percent and 7.9 percent respectively. As expected, the prevalences of stroke, dementia, parkinsonism increased with advancing age. There was a female predominance in all the four conditions.

IMPLICATIONS: These prevalence data would give clinicians and policy makers an estimate of how frequent these five common neurological illnesses affect the Filipino adult population. This knowledge is important for health planning, prioritization of health projects and as baseline for future prevalence studies. (Author)

Stroke ; Dementia ; Migraine Disorders ; Parkinsonism Disorders ; Epilepsy ; Prevalence ; Cross-sectional Studies

Objective: The objectives of this study are: 1) to determine the prevalence of 3 atherosclerotic diseases (angina, stroke and claudication) in the Philippines; and 2) to determine the prevalence of 5 risk factors for these diseases (dyslipedemia, diabetes, hypertension, obesity and smoking). Methodology: Using a multi-staged cluster sampling methodology, this study evaluated 4,753 adults aged 20 or more, from 2,636 households, 79 provinces and 17 regions. The survey instruments included validated questionnaires, anthropometric measurements, and blood tests. Results: The prevalence rates of angina, stroke and claudication in adult Filipinos were 12.5 percent, 1.9 percent, and 4.2 percent respectively. The prevalence rates of various risk factors were 8.5 percent for hypercholesterolemia (total cholesterol > 240mg/dl), 4.6 percent for diabetes (based on fasting blood sugar >125mg/dl or a previous history of diabetes), and 17.4 percent for hypertension (BP >140/90 mm Hg on 2 visits, or a previous history of hypertension). The prevalence of obesity was 3.2 percent in men and 6.6 percent in women when body mass index (BMI) was used. These rates rose to 12.1 percent and 54.8 percent respectively when waist-hip ratio (WHR) was used. The prevalence of current smoking was 56.3 percent in men, 12.1 percent in women, and 34.8 percent overall. Smoking, by far, was the most common risk factor noted. Discussion: These data on atherosclerosis-related diseases and risk factors from the NNHeS provide clinicians and policy-makers a bird's eye view of the Philippine situation with respect to vascular disease and its risk factors. These data may be used for policy formulation and program prioritization. In addition, the information may serve as baseline measures to evaluate the success or failure of atherosclerosis control programs in the country. A 2nd NNHeS is planned in the year 2008.

Atherosclerosis ; Coronaryartery Disease ; Cerebrovascular Accident ; Diabetes Mellitus ; Hypertension ; Dyslipidemias ; Smoking ; Obesity