Incidence of the different stages of status epilepticus in Eastern Finland: A population-based study.

OBJECTIVE: The objective of this study was to determine the incidence in Eastern Finland of the different stages of status epilepticus (SE): 1) at the early stage of SE (a prolonged seizure lasting over 5 min);, 2) refractory SE (RSE), and 3) super-refractory SE (SRSE). METHODS: Firstly, we conducted a retrospective study on the incidence and outcome of intensive care unit (ICU)-treated RSE and SRSE in the adult population (≥16 years) in Kuopio University Hospital (KUH)'s special care responsibility area (840,000 inhabitants). Secondly, we conducted a prospective study using the International League Against Epilepsy (ILAE)'s new definition for SE (prolonged seizures lasting over 5 min), in adult (≥16 years) patients in the KUH municipality district (North Savo, 248,000 inhabitants). RESULTS: The retrospective study on ICU-treated RSE and SRSE from 2010 to 2012 identified 75 patients with RSE, of whom 21% were treated as SRSE, resulting in an annual age-adjusted incidence of ICU-treated RSE of 3.0/100,000 (95% confidence interval [CI]: 2.4-3.8) and 0.6/100,000 (95% CI: 0.4-1.0) for SRSE. In the prospective study of early stage SE (seizures lasting over 5 min), we identified 151 consecutive episodes during the 9-month study period in 2015, corresponding to an annual age-adjusted incidence of 81.1/100,000 (95% CI: 75.8-87.0). In this study, 11 seizure episodes became refractory, resulting in an age-adjusted incidence of RSE of 6.0/100,000 (95% CI: 3.4-10.4), of which seven were treated in the ICU [3.8/100,000 (95% CI: 1.8-7.8)], four were treated palliatively [2.2/100,000 (95% CI: 0.82-5.7)], and two evolved to SRSE [1.1/100,000 (95% CI: 0.3-4.3)]. CONCLUSIONS: The new ILAE 2015 definition of SE resulted in a four-fold increase in incidence of SE compared to the earlier 30-min definition reported earlier in Europe. In the epidemiology of RSE, the incidence of ICU-treated RSE, palliatively treated RSE, and SRSE needs to be separated. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures.

Characterization of human memory CD4(+) T-cell responses to the dog allergen Can f 4.

BACKGROUND: The recently identified dog lipocalin allergen Can f 4 is an important respiratory allergen. OBJECTIVE: We sought to comprehensively characterize the memory CD4(+) T-cell responses of allergic and nonallergic subjects to Can f 4. METHODS: Can f 4-specific CD4(+)CD45RO(+) T-cell lines (TCLs) from allergic and healthy subjects were established and characterized by their functional and phenotypic properties. The epitope specificity of the TCLs was tested with 48 overlapping 16-mer peptides spanning the sequence of Can f 4. HLA restriction of the specific TCLs and the binding capacity of the epitope-containing peptides to common HLA class II molecules were studied. RESULTS: Can f 4-specific memory CD4(+) TCLs were obtained at an 8-fold higher frequency from allergic than from nonallergic subjects. Functionally, the TCLs of allergic subjects exhibited a higher T-cell receptor avidity and expression of CD25 and predominantly produced IL-4 and IL-5. The TCLs of nonallergic subjects mostly secreted IFN-γ and IL-10, with high CXCR3 expression. Several distinct T-cell epitope regions along the allergen were identified. Importantly, the peptides from the region between amino acids 43 and 67 showed promiscuous HLA-binding capacity and induced memory CD4(+) T-cell responses in 90% of the allergic donors. CONCLUSION: Productive TH2-deviated memory T-cell responses to Can f 4 are observed in allergic but not nonallergic subjects. A 19-mer peptide sequence covering the core of the immunodominant region of the allergen is a potential target for the development of peptide-based allergen immunotherapy.

Isolated sternal fracture after low-energy trauma in a geriatric patient: a case report.

BACKGROUND: Falls are a common cause of emergency department (ED) visits for the older population. If osteoporosis is present, even falls from standing height can lead to unusual fractures normally associated with high-energy trauma. In this report, we analyze a rare case of an isolated sternal fracture with an unusual mechanism of injury. Our discussion aims to improve care for older adults with fall-related fractures. CASE PRESENTATION: An 86-year-old female presented in the ED of our hospital with a complaint of chest pain. She recalled a fall at home the previous day and described how her fist was impacted between the floor and her chest. A physical examination revealed local tenderness in the mid-chest. A lateral chest x-ray indicated a sternal fracture, and a chest computed tomography scan ruled out concomitant injuries. There were no acute changes on her electrocardiogram (ECG). Conservative outpatient treatment was started, and referrals were made with a recommendation to initiate fall prevention measures and osteoporosis screening in primary health care. CONCLUSIONS: Geriatric patients can present in the ED with a rare sternal fracture even after only a minor chest trauma. Appropriate imaging and an ECG are warranted to exclude life-threatening additional injuries. An in-depth physical examination and an understanding of the exact mechanism of injury are important to avoid missing fractures in unexpected locations. Modern ED physicians could have an important role in the secondary prevention of fall-related fractures for geriatric patients.

Status epilepticus: Practice variation and adherence to treatment guideline in a large community hospital.

PURPOSE: To evaluate the treatment of status epilepticus (SE) and adherence to treatment guideline in a large Finnish community hospital. MATERIALS AND METHODS: A consecutive series of 137 patients treated in the emergency department of Kuopio University Hospital. Enrollment took place between March 23 and December 31, 2015. Pediatric patients and postanoxic seizures were excluded. The Finnish Status Epilepticus Current Care Guideline was used as the evaluation benchmark. RESULTS: Seventeen patients recovered spontaneously. First-line treatment was given to 108 patients with 35.2% efficacy. Second-line treatment was given to 81 patients with 87.7% efficacy. Six patients with refractory SE received successful third-line treatment and four were excluded from intensive care because of futility. The starting dose of a first-line drug was lower than the lowest therapeutic dose in 37.0% of the patients. The escalation from first- to second-line treatment took longer than 60 min in 55.1% of the 70 patients who received both treatments. The first loading dose of a second-line drug was markedly low (<80% of the recommended dose) in 26.2% of the 81 patients treated with second-line drugs. CONCLUSIONS: Prompt and effective pharmacotherapy is the cornerstone of good SE treatment. Subtherapeutic doses of first-line benzodiazepines should be avoided. Benzodiazepine-resistant SE must be recognized early to facilitate rapid treatment escalation. The quality of second-line treatment suffers from excessive delays and inadequate weight-based dosing of antiseizure medications.

Outcome of status epilepticus and the predictive value of the EMSE and STESS scores: A prospective study.

PURPOSE: To assess the short-term outcome of status epilepticus (SE) and test the Epidemiology-based Mortality score in Status Epilepticus (EMSE) and the Status Epilepticus Severity Score (STESS) performance in outcome prediction. METHODS: Consecutive adults with SE in the Kuopio University Hospital emergency department were recruited between March 23 and December 31, 2015. The one-month outcome was assessed by a combined phone interview and medical record review using the Glasgow Outcome Scale-Extended. The prognostic performance of the EMSE-EAC (EMSE using the combination of etiology, age and comorbidity) and STESS were statistically evaluated. RESULTS: We recorded 151 SE episodes in 137 patients, of whom 47 had a first-time epileptic event (seizure or SE). Of the SE episodes, 9.0% resulted in death, 31.6% in functional decline. For mortality prediction, the AUCs of the EMSE-EAC and STESS were 0.790 (95% CI: 0.633-0.947) and 0.736 (95% CI: 0.559-0.914), respectively. The optimal cutoff points were ≥ 34 for the EMSE-EAC and ≥ 4 for STESS. Negative predictive values for mortality using the EMSE-EAC-34 and STESS-4 were 97.5% and 96.7%, respectively. For functional decline prediction, the EMSE-EAC yielded statistically insignificant results, the STESS performance was poor (AUC = 0.621, 95% CI: 0.519-0.724). CONCLUSIONS: Over 40% of SE patients suffer adverse outcomes. The EMSE-EAC and STESS are useful in short-term mortality prediction, with a high negative predictive value. The optimized cutoff points for the EMSE-EAC and STESS were ≥ 34 and ≥ 4 for cohort, respectively.

Treatment delay in status epilepticus - more effective prehospital symptom recognition warranted.

BACKGROUND: The outcome of status epilepticus (SE) can be improved by facilitating early recognition and treatment with antiepileptic drugs. The purpose of this study was to analyze the treatment delay of SE in a prospectively recruited patient cohort. Improvements to the treatment process are suggested. METHODS: Consecutive adult patients with SE were recruited in the emergency department of Kuopio University Hospital (KUH) between March 23 and December 31, 2015. SE was defined as a prolonged (> 5 min) epileptic seizure or recurrent tonic-clonic seizures (≥ 3 seizures within any 24 h). Diagnostic and treatment delays and the features of SE were subject to statistical analysis. RESULTS: We recorded 151 cases of SE during the study period. First-line treatment was initiated outside of hospital in 79 cases (52.3%), with a significantly shorter median delay compared to intrahospital initiation (28 min vs. 2 h 5 min, p < 0.001). Forty-six episodes of SE (30.5%) were not recognized during the prehospital phase. The median delay in recognition of tonic-clonic SE (23 min) was significantly shorter than in focal aware (2 h 0 min, p = 0.045) or focal impaired awareness SE (2 h 25 min, p < 0.001). Second-line treatment was used in 91 cases (60.3%), with a median delay of 2 h 42 min. Anesthesia was used in seven cases (4.6%) with refractory SE, with a median delay of 6 h 40 min. CONCLUSIONS: SE is often not recognized during the prehospital phase of treatment, which delays the initiation of first-line treatment. Intrahospital delay could be reduced by streamlining patient transition between the three lines of treatment.