Seizures after initiation of rewarming in cooled infants with hypoxic ischaemic encephalopathy.

BACKGROUND: Seizures after initiation of rewarming from therapeutic hypothermia for neonatal encephalopathy are well recognised but not easy to predict. METHODS: A secondary analysis was performed of NEOLEV2 trial data, a multicentre randomised trial of levetiracetam versus phenobarbital for neonatal seizures. Enrolled infants underwent continuous video EEG (cEEG) monitoring. The trial data were reviewed for 42 infants with seizures during therapeutic hypothermia and 118 infants who received therapeutic hypothermia but had no seizures on cEEG. RESULTS: Overall, 112 of 160 (70%) had cEEG monitoring continued until rewarming was completed. Of the 42 infants with prior seizures, there were 30 infants with valid cEEG available and seizures occurred following the initiation of rewarming in 8 (26.6%). For the 118 seizure-naive infants, 82 (69.5%) continued cEEG until either rewarming was completed or 90 h of age and none had documented seizures. CONCLUSION: Overall, just over a quarter of infants with prior seizures had cEEG evidence of at least one seizure in the 24 h after initiation of rewarming but no seizure-naive infant had cEEG evidence of seizure(s) on rewarming. Critically, by reporting the two groups separately, the data can provide guidance on the duration of EEG monitoring. IMPACT: Infants with hypoxic ischaemic encephalopathy who have cEEG evidence of seizures during therapeutic hypothermia have a significant risk of further seizures on rewarming. For infants with hypoxic ischaemic encephalopathy but no cEEG evidence of seizures during therapeutic hypothermia, there is very little risk of de novo seizures. Ongoing work utilising large cohorts may generate EEG criteria that refine estimates of risk for rewarming seizures. Based on current experience, if seizures have occurred during therapeutic hypothermia for hypoxic ischaemic encephalopathy, the EEG monitoring should be continued during rewarming and for 12 h thereafter to minimise the risk of missing an event.

Optical Flow Estimation Improves Automated Seizure Detection in Neonatal EEG.

PURPOSE: Existing automated seizure detection algorithms report sensitivities between 43% and 77% and specificities between 56% and 90%. The algorithms suffer from false alarms when applied to neonatal EEG because of the high degree of nurse handling and rhythmic patting used to soothe neonates. Computer vision technology that quantifies movement in real time could distinguish artifactual motion and improve automated neonatal seizure detection algorithms. METHODS: The authors used video EEG recordings from 43 neonates undergoing monitoring for seizures as part of the NEOLEV2 clinical trial. The Persyst neonatal automated seizure detection algorithm ran in real time during study EEG acquisitions. Computer vision algorithms were applied to extract detailed accounts of artifactual movement of the neonate or people near the neonate though dense optical flow estimation. RESULTS: Using the methods mentioned above, 197 periods of patting activity were identified and quantified, of which 45 generated false-positive automated seizure detection events. A binary patting detection algorithm was trained with a subset of 470 event videos. This supervised detection algorithm was applied to a testing subset of 187 event videos with 8 false-positive events, which resulted in a 24% reduction in false-positive automated seizure detections and a 50% reduction in false-positive events caused by neonatal care patting, while maintaining 11 of 12 true-positive seizure detection events. CONCLUSIONS: This work presents a novel approach to improving automated seizure detection algorithms used during neonatal video EEG monitoring. This artifact detection mechanism can improve the ability of a seizure detector algorithm to distinguish between artifact and true seizure activity.

Failure of the Milwaukee protocol in a child with rabies.

Rabies has the highest case-fatality rate of all infectious diseases, with 50,000 cases occurring annually worldwide. In 2004 an unvaccinated adolescent survived after novel therapy. We report the management of a child with rabies. Although the implementation of this same therapeutic protocol was successful, the child died after 1 month of hospitalization.

Does the first hour of continuous electroencephalography predict neonatal seizures?

OBJECTIVE: Prolonged continuous video-electroencephalography (cEEG) is recommended for neonates at risk of seizures. The cost and expertise required to provide a real-time response to detected seizures often limits its utility. We hypothesised that the first hour of cEEG could predict subsequent seizures. DESIGN AND SETTING: Retrospective multicentre diagnostic accuracy study. PATIENTS: 266 term neonates at risk of seizure or with suspected seizures. INTERVENTION: The first hour of cEEG was graded by expert and novice interpreters as normal, mildly, moderately or severely abnormal; seizures were identified. MAIN OUTCOME MEASURES: Association between abnormalities in the first hour of cEEG and the presence of seizures during total cEEG monitoring. RESULTS: 50/98 (51%) of neonates who developed seizures had their first seizure in the first hour of cEEG monitoring. The 'time-to-event' risk of seizure from 0 to 96 hours was 0.38 (95% CI 0.32 to 0.44) while the risk in the first hour was 0.19 (95% CI 0.15 to 0.24). cEEG background was normal in 48% of neonates, mildly abnormal in 30%, moderately abnormal in 13% and severely abnormal in 9%. Inter-rater agreement for determination of background was very good (weighted kappa=0.81, 95% CI 0.72 to 0.91). When neonates with seizures during the first hour were excluded, an abnormal background resulted in 2.4 times increased risk of seizures during the subsequent monitoring period (95% CI 1.3 to 4.4, p<0.003) while a severely abnormal background resulted in a sevenfold increased risk (95% CI 3.4 to 14.3, p<0.0001). CONCLUSIONS: The first hour of cEEG in at-risk neonates is useful in identifying and predicting whether seizures occur during cEEG monitoring up to 96 hours. This finding enables identification of high-risk neonates who require closer observation.

Levetiracetam Versus Phenobarbital for Neonatal Seizures: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: There are no US Food and Drug Administration-approved therapies for neonatal seizures. Phenobarbital and phenytoin frequently fail to control seizures. There are concerns about the safety of seizure medications in the developing brain. Levetiracetam has proven efficacy and an excellent safety profile in older patients; therefore, there is great interest in its use in neonates. However, randomized studies have not been performed. Our objectives were to study the efficacy and safety of levetiracetam compared with phenobarbital as a first-line treatment of neonatal seizures. METHODS: The study was a multicenter, randomized, blinded, controlled, phase IIb trial investigating the efficacy and safety of levetiracetam compared with phenobarbital as a first-line treatment for neonatal seizures of any cause. The primary outcome measure was complete seizure freedom for 24 hours, assessed by independent review of the EEGs by 2 neurophysiologists. RESULTS: Eighty percent of patients (24 of 30) randomly assigned to phenobarbital remained seizure free for 24 hours, compared with 28% of patients (15 of 53) randomly assigned to levetiracetam (P < .001; relative risk 0.35 [95% confidence interval: 0.22-0.56]; modified intention-to-treat population). A 7.5% improvement in efficacy was achieved with a dose escalation of levetiracetam from 40 to 60 mg/kg. More adverse effects were seen in subjects randomly assigned to phenobarbital (not statistically significant). CONCLUSIONS: In this phase IIb study, phenobarbital was more effective than levetiracetam for the treatment of neonatal seizures. Higher rates of adverse effects were seen with phenobarbital treatment. Higher-dose studies of levetiracetam are warranted, and definitive studies with long-term outcome measures are needed.

Assessment of biodegradation in ancient archaeological wood from the Middle Cemetery at Abydos, Egypt.

Abydos is a large, complex archaeological site located approximately 500 km south of Cairo in Upper Egypt. The site has served as a cemetery for thousands of years and is where most of the Early Dynastic royal tombs are located. North Abydos includes the Middle Cemetery and the North Cemetery, which are separated from each other by a wadi. The Middle Cemetery was the burial ground for important Sixth Dynasty (2407-2260 BC) officials and over time for thousands of elite and non-elite individuals as well. Excavations at the core area of the Old Kingdom mortuary landscape have revealed many culturally important wooden objects but these are often found with extensive deterioration that can compromise their preservation. The objectives of this study were to characterize the biodegradation that has taken place in excavated wooden objects, elucidate the type of wood degradation present, obtain information on soil properties at the site and identify fungi currently associated with the wood and soils. Light and scanning electron microscopy studies were used to observe the micromorphological characteristics of the wood, and culturing on different media was done to isolate fungi. Identification of the fungi was done by examining morphological characteristics and extracting rDNA from pure cultures and sequencing the ITS region. Wooden objects, made from Cedrus, Juniperus and Acacia as well as several unidentified hardwoods, were found with extensive degradation and were exceedingly fragile. Termite damage was evident and frass from the subterranean termites along with sand particles were present in most woods. Evidence of soft rot attack was found in sections of wood that remained. Fungi isolated from wood and soils were identified as species of Aspergillus, Chaetomium, Cladosporium, Fusarium, Penicillium, Stemphylium Talaromyces and Trichoderma. Results provide important information on the current condition of the wood and gives insights to the identity of the fungi in wood and soils at the site. These results provide needed information to help develop conservation plans to preserve these degraded and fragile wooden objects.

Assessing the Feasibility of Providing a Real-Time Response to Seizures Detected With Continuous Long-Term Neonatal Electroencephalography Monitoring.

PURPOSE: Continuous video electroencephalography (cEEG) monitoring is the recommended gold standard of care for at-risk neonates but is not available in many Neonatal Intensive Care Units (NICUs). To conduct a randomized treatment trial of levetiracetam for the first-line treatment of neonatal seizures (the NEOLEV2 trial), we developed a monitoring infrastructure at five NICUs, implementing recent technological advancements to provide continuous video EEG monitoring and real-time response to seizure detection. Here, we report on the feasibility of providing this level of care. METHODS: Twenty-five key informant interviews were conducted with study neurologists, neonatologists, coordinators, and EEG technicians from the commercial EEG monitoring company Corticare. A general inductive approach was used to analyze these qualitative data. RESULTS: A robust infrastructure for continuous video EEG monitoring, remote review, and real-time seizure detection was established at all sites. At the time of this survey, 260 babies had been recruited and monitored for 2 to 6 days. The EEG technician review by the commercial EEG monitoring company was reassuring to families and neonatologists and led to earlier detection of seizures but did not reduce work load for neurologists. Neurologists found the automated neonatal seizure detector algorithm provided by the EEG software company Persyst useful, but the accuracy of the algorithm was not such that it could be used without review by human expert. Placement of EEG electrodes to initiate monitoring, especially after hours, remains problematic. CONCLUSIONS: Technological advancements have made it possible to provide at-risk neonates with continuous video EEG monitoring, real-time detection of and response to seizures. However, this standard of care remains unfeasible in usual clinical practice. Chief obstacles remain starting a recording and resourcing the real-time specialist review of suspect seizures.

Consistency in children's reports of sexual and physical abuse.

OBJECTIVE: The goal of the present study was to investigate the consistency of children's reports of sexual and physical abuse. METHOD: A group of 222 children, ages 3-16 years, participated. As part of legal investigations, the children were interviewed twice about their alleged experiences of abuse. The consistency of children's reports of sexual and physical abuse was examined in the two interviews, in relation to age, type of abuse, gender, memory, suggestibility, and cognitive capabilities. RESULTS: Older children were more consistent than younger children in their reports of sexual and physical abuse. Children were more consistent when reporting sexual abuse than physical abuse. Girls were more consistent than boys in sexual abuse reports. Consistency in sexual abuse reports was predicted by measures of memory, whereas consistency in physical abuse reports was not. Cognitive abilities did not predict consistency in sexual abuse or physical abuse reports. CONCLUSIONS: Implications for understanding children's allegations of abuse are discussed.

Effects of social support on children's eyewitness reports: a test of the underlying mechanism.

Research on children's eyewitness testimony demonstrates that interviewer-provided social support given during a mock forensic interview helps children resist an interviewer's misleading suggestions about past events. We proposed and tested 1 potential mechanism underlying support effects: "Resistance Efficacy," or children's perceived self-efficacy for resisting an interviewer's suggestions. Eighty-one 6- and 7-year-old children experienced a play event, then were interviewed about the event with misleading and specific questions. Consistent with prior research, children interviewed by a supportive person were more resistant to misleading suggestions than were those interviewed by a nonsupportive person. Although Resistance Efficacy did not mediate the effects of interviewer support in the full sample, additional analyses revealed that Resistance Efficacy may be a mediator for older, but not younger, children. Contrary to predictions, children's preexisting social support reserves were not related to children's interview accuracy nor to perceived Resistance Efficacy. Implications for psychological theory are discussed, as well as implications for understanding and improving children's eyewitness reports.

Memory and suggestibility in maltreated children: age, stress arousal, dissociation, and psychopathology.

The present study was designed to assess children's memory and suggestibility in the context of ongoing child maltreatment investigations. One hundred eighty-nine 3-17-year-olds involved in evaluations of alleged maltreatment were interviewed with specific and misleading questions about an anogenital examination and clinical assessment. For the anogenital examination, children's stress arousal was indexed both behaviorally and physiologically. For all children, individual-difference data were gathered on intellectual and short-term memory abilities, general psychopathology, and dissociative tendencies. Interviewers' ratings were available for a subset of children concerning the amount of detail provided in abuse disclosures. Results indicated that general psychopathology, short-term memory, and intellectual ability predicted facets of children's memory performance. Older compared to younger children evinced fewer memory errors and greater suggestibility resistance. Age was also significantly related to the amount of detail in children's abuse disclosures. Neither dissociation nor stress arousal significantly predicted children's memory. Implications for understanding maltreated children's eyewitness memory are discussed.