Reactive oxygen species in status epilepticus.

There has been growing evidence for a critical role of oxidative stress in neurodegenerative disease, providing novel targets for disease modifying treatments. Although antioxidants have been suggested and tried in the treatment of epilepsy, it is only recently that the pivotal role of oxidative stress in the pathophysiology of status epilepticus has been recognized. Although conventionally thought to be generated by mitochondria, reactive oxygen species during status epilepticus and prolonged seizure are generated mainly by NADPH (nicotinamide adenine dinucleotide phosphate) oxidase (stimulated by NMDA receptor activation). Excessive production of reactive oxygen species results in lipid peroxidation, DNA damage, enzyme inhibition, and mitochondrial damage, culminating in neuronal death. Antioxidant therapy has been hampered by poor CNS penetration and rapid consumption by oxidants. However, alternative approaches such as inhibiting NADPH oxidase or increasing endogenous antioxidant defenses through activation of the transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2) could avoid these problems. Small molecules that increase Nrf2 activation have proven to be not only effective neuroprotectants following status epilepticus, but also potently antiepileptogenic. There are "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".

Decreasing the risk of sudden unexpected death in epilepsy: structured communication of risk factors for premature mortality in people with epilepsy.

BACKGROUND AND PURPOSE: Good practice guidelines highlight the importance of making people with epilepsy aware of the risk of premature mortality in epilepsy particularly due to sudden unexpected death in epilepsy (SUDEP). The SUDEP and Seizure Safety Checklist ('Checklist') is a structured risk communication tool used in UK clinics. It is not known if sharing structured information on risk factors allows individuals to reduce SUDEP and premature mortality risks. The aim of this study was to ascertain if the introduction of the Checklist in epilepsy clinics led to individual risk reduction. METHODS: The Checklist was administered to 130 consecutive people with epilepsy attending a specialized epilepsy neurology clinic and 129 attending an epilepsy intellectual disability (ID) clinic within a 4-month period. At baseline, no attendees at the neurology clinic had received formal risk advice, whereas all those attending the ID clinic had received formal risk advice on multiple occasions for 6 years. The Checklist was readministered 1 year later to each group and scores were compared with baseline and between groups. RESULTS: Of 12 risk factors considered, there was an overall reduction in mean risk score for the general (P = 0.0049) but not for the ID (P = 0.322) population. Subanalysis of the 25% of people at most risk in both populations showed that both sets had a significant reduction in risk scores (P < 0.001). CONCLUSION: Structured discussion results in behavioural change that reduces individual risk factors. This impact seems to be higher in those who are at current higher risk. It is important that clinicians share risk information with individuals as a matter of public health and health promotion.

Maternal pre-gravid cardiometabolic health and infant birthweight: A prospective pre-conception cohort study.

BACKGROUND AND AIMS: Both low birthweight and high birthweight have been associated with the development of cardiometabolic disease in adulthood, possibly reflecting the effect of intrauterine fetal programming. As developmental programming can begin before conception, pre-gravid factors that predict birthweight may be relevant in this context. However, little is known about such factors. Thus, we established a pre-conception cohort to identify maternal pre-gravid cardiometabolic determinants of infant birthweight. METHODS AND RESULTS: In this prospective observational cohort study, 1484 newly-married women in Liuyang, China, underwent baseline (pre-gravid) evaluation and then were followed across a subsequent pregnancy. Pre-gravid cardiometabolic characterization consisted of clinical (anthropometry, blood pressure) and biochemical evaluation (total/LDL/HDL cholesterol, triglycerides, glucose) at median 20 weeks before a singleton pregnancy. Mean birthweight was 3294 ± 444 g, with 173 neonates large-for-gestational-age (LGA) and 110 small-for-gestational-age (SGA). On multiple linear regression analysis, positive determinants of birthweight were maternal age, pre-gravid body mass index (BMI), weight gain in pregnancy, length of gestation, and male infant (all p ≤ 0.0003). On logistic regression analysis, independent predictors of an LGA delivery were maternal age (OR = 1.10 per year, 95%CI 1.03-1.18), pre-gravid BMI (OR = 1.21 per kg/m2, 1.07-1.37), and gestational weight gain (OR = 1.10 per kg, 1.06-1.14). The only independent predictor of SGA was gestational weight gain (OR = 0.93 per kg, 0.89-0.97). CONCLUSION: Maternal weight before and during pregnancy is the predominant cardiometabolic determinant of infant birthweight, rather than pre-gravid blood pressure, glucose or lipid profile.

A study of the electro-haemodynamic coupling using simultaneously acquired intracranial EEG and fMRI data in humans.

In current fMRI studies designed to map BOLD changes related to interictal epileptiform discharges (IED), which are recorded on simultaneous EEG, the information contained in the morphology and field extent of the EEG events is exclusively used for their classification. Usually, a BOLD predictor based on IED onset times alone is constructed, effectively treating all events as identical. We used intracranial EEG (icEEG)-fMRI data simultaneously recorded in humans to investigate the effect of including any of the features: amplitude, width (duration), slope of the rising phase, energy (area under the curve), or spatial field extent (number of contacts over which the sharp wave was observed) of the fast wave of the IED (the sharp wave), into the BOLD model, to better understand the neurophysiological origin of sharp wave-related BOLD changes, in the immediate vicinity of the recording contacts. Among the features considered, the width was the only one found to explain a significant amount of additional variance, suggesting that the amplitude of the BOLD signal depends more on the duration of the underlying field potential (reflected in the sharp wave width) than on the degree of neuronal activity synchrony (reflected in the sharp wave amplitude), and, consequently, that including inter-event variations of the sharp wave width in the BOLD signal model may increase the sensitivity of forthcoming EEG-fMRI studies of epileptic activity.

Maternal folate status and obesity/insulin resistance in the offspring: a systematic review.

OBJECTIVE: Prenatal folic acid supplementation or maternal folate sufficiency may protect the offspring from obesity and insulin resistance. This study aims to summarize the findings of association between prenatal folic acid supplementation/maternal folate sufficiency and obesity/insulin resistance in the offspring. METHODS: Twelve databases were searched for both published and unpublished work of prenatal folic acid supplementation/maternal folate status up to 1 July 2014. Experimental and observational studies on animals and human beings were included based on the eligibility criteria. There were no limits to the time period and language of publication. The study quality was assessed with a 10-Point Scale for Scientific Methodology. RESULTS: The search identified 2548 records. Nine animal studies and five human studies satisfied search criteria were included. Five of these nine animal studies showed a protective effect of folic acid. Of the five human studies, one showed a protective effect of folic acid, two showed a harmful effect and two showed uncertain results. CONCLUSIONS: Data from both animal studies and human studies are inconsistent. Future researches with sophisticated designs are needed to demonstrate the potential protective effect of maternal folate on obesity/insulin resistance in the offspring in animal models and human pregnancies.

Antiviral medication use in a cohort of pregnant women during the 2009-2010 influenza pandemic.

Preventing influenza-like illness (ILI) during pregnancy with antiviral medication use (AVMU) can mitigate serious health risks to mother and foetus. We report on AVMU in pregnant women in Ontario, Canada, and describe characteristics of AVMU during the 2009-2010 H1N1 pandemic. Rates and risk estimates of AVMU were compared across multiple categories and stratified across ILI infection status. Increased AVMU was observed in women with influenza infections, active smokers, those vaccinated against influenza, and those with pre-existing co-morbidities. Decreased AVMU was observed in women with multiple gestations, and those in neighbourhoods of high immigrant concentrations. Our stratified analysis indicated that the observed patterns differed by ILI infection status. We demonstrated that once infected, women across multiple groups were equally likely to use antiviral medications. In this report we also propose possible clinical explanations for the observed differences in AVMU, which will be useful in planning prevention initiatives for future pandemics.

Beta-blockers increase the risk of being born small for gestational age or of being institutionalised during infancy.

OBJECTIVE: To compare infant outcomes between mothers with hypertension treated by beta-blockers alone and by methyldopa alone during pregnancy. DESIGN: Historical cohort study. SETTING: Saskatchewan, Canada. POPULATION: Women who delivered a singleton birth in Saskatchewan during the periods from 1 January 1980 to 30 June 1987 or from 1 January 1990 to 31 December 2005 (women who delivered between 1 July 1987 and 31 December 1989 were excluded because the information recorded on maternal drug use during pregnancy is incomplete) with a diagnosis of a hypertensive disorder during pregnancy, and who were dispensed only beta-blockers (n = 416) or only methyldopa (n = 1000). METHODS: Occurrences of adverse infant outcomes were compared between women who received beta-blockers only and women who received methyldopa only during pregnancy, first in all eligible women, and then in women with chronic hypertension and in women with gestational hypertension or pre-eclampsia/eclampsia, separately. Multiple logistic regression analyses were performed to adjust for potential confounding. MAIN OUTCOME MEASURES: Small for gestational age (SGA) < 10th percentile, SGA < 3rd percentile, preterm birth, stillbirth, institutionalisation for respiratory distress syndrome (RDS), sepsis, seizure during infancy, and infant death. RESULTS: Adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) for infants born to mothers with chronic hypertension who were dispensed beta-blockers only, as compared with infants born to mothers who were dispensed methyldopa only, during pregnancy were: 1.95 (1.21-3.15), 2.17 (1.06-4.44), and 2.17 (1.09-4.34), respectively, for SGA < 10th percentile, SGA < 3rd percentile, and being institutionalised during infancy. CONCLUSIONS: For infants born to mothers with chronic hypertension, compared with those treated by methyldopa alone, those treated by beta-blockers appear to be at increased rates of SGA and hospitalisation during infancy.

Evaluation of the impact of fetal fibronectin test implementation on hospital admissions for preterm labour in Ontario: a multiple baseline time-series design.

OBJECTIVE: To determine the impact of a health system-wide fetal fibronectin (fFN) testing programme on the rates of hospital admission for preterm labour (PTL). DESIGN: Multiple baseline time-series design. SETTING: Canadian province of Ontario. POPULATION: A retrospective population-based cohort of antepartum and delivered obstetrical admissions in all Ontario hospitals between 1 April 2002 and 31 March 2010. METHODS: International Classification of Diseases codes in a health system-wide hospital administrative database were used to identify the study population and define the outcome measure. An aggregate time series of monthly rates of hospital admissions for PTL was analysed using segmented regression models after aligning the fFN test implementation date for each institution. MAIN OUTCOME MEASURE: Rate of obstetrical hospital admission for PTL. RESULTS: Estimated rates of hospital admission for PTL following fFN implementation were lower than predicted had pre-implementation trends prevailed. The reduction in the rate was modest, but statistically significant, when estimated at 12 months following fFN implementation (-0.96 hospital admissions for PTL per 100 preterm births; 95% confidence interval [CI], -1.02 to -0.90, P = 0.04). The statistically significant reduction was sustained at 24 and 36 months following implementation. CONCLUSIONS: Using a robust quasi-experimental study design to overcome confounding as a result of underlying secular trends or concurrent interventions, we found evidence of a small but statistically significant reduction in the health system-level rate of hospital admissions for PTL following implementation of fFN testing in a large Canadian province.

Imaging haemodynamic changes related to seizures: comparison of EEG-based general linear model, independent component analysis of fMRI and intracranial EEG.

BACKGROUND: Simultaneous EEG-fMRI can reveal haemodynamic changes associated with epileptic activity which may contribute to understanding seizure onset and propagation. METHODS: Nine of 83 patients with focal epilepsy undergoing pre-surgical evaluation had seizures during EEG-fMRI and analysed using three approaches, two based on the general linear model (GLM) and one using independent component analysis (ICA): The results were compared with intracranial EEG. RESULTS: The canonical GLM analysis revealed significant BOLD signal changes associated with seizures on EEG in 7/9 patients, concordant with the seizure onset zone in 4/7. The Fourier GLM analysis revealed changes in BOLD signal corresponding with the results of the canonical analysis in two patients. ICA revealed components spatially concordant with the seizure onset zone in all patients (8/9 confirmed by intracranial EEG). CONCLUSION: Ictal EEG-fMRI visualises plausible seizure related haemodynamic changes. The GLM approach to analysing EEG-fMRI data reveals localised BOLD changes concordant with the ictal onset zone when scalp EEG reflects seizure onset. ICA provides additional information when scalp EEG does not accurately reflect seizures and may give insight into ictal haemodynamics.

Premature mortality in refractory partial epilepsy: does surgical treatment make a difference?

BACKGROUND: Epilepsy carries an increased risk of premature death. For some people with intractable focal epilepsy, surgery offers hope for a seizure-free life. The authors aimed to see whether epilepsy surgery influenced mortality in people with intractable epilepsy. METHODS: The authors audited survival status in two cohorts (those who had surgery and those who had presurgical assessment but did not have surgery). RESULTS: There were 40 known deaths in the non-surgical group (3365 person years of follow-up) and 19 in the surgical group (3905 person-years of follow-up). Non-operated patients were 2.4 times (95% CI 1.4 to 4.2) as likely to die as those who had surgery. They were 4.5 times (95% CI 1.9 to 10.9) as likely to die a probable epilepsy-related death. In the surgical group, those with ongoing seizures 1 year after surgery were 4.0 (95% CI 1.2 to 13.7) times as likely to die as those who were seizure-free or who had only simple partial seizures. Time-dependent Cox analysis showed that the yearly outcome group did not significantly affect mortality (HR 1.3, 95% CI 0.9 to 1.8). CONCLUSION: Successful epilepsy surgery was associated with a reduced risk of premature mortality, compared with those with refractory focal epilepsy who did not have surgical treatment. To some extent, the reduced mortality is likely to be conferred by inducing freedom from seizures. It is not certain whether better survival is attributable only to surgery, as treatment decisions were not randomised, and there may be inherent differences between the groups.

CARTR Plus: the creation of an ART registry in Canada.

STUDY QUESTION: What is the status of fertility treatment and birth outcomes documented over the first 6 years of the Canadian Assisted Reproductive Technologies Register (CARTR) Plus registry? SUMMARY ANSWER: The CARTR Plus registry is a robust database containing comprehensive Canadian fertility treatment data to assist with providing evidence-based rationale for clinical practice change. WHAT IS KNOWN ALREADY: The rate of infertility is increasing globally and having data on fertility treatment cycles and outcomes at a population level is important for accurately documenting and effecting changes in clinical practice. STUDY DESIGN SIZE DURATION: This is a descriptive manuscript of 183 739 fertility treatment cycles from 36 Canadian clinics over 6 years from the CARTR Plus registry. PARTICIPANTS/MATERIALS SETTING METHODS: Canadian ART treatment cycles from 2013 through 2018 were included. This manuscript described trends in type of fertility treatment cycles, pregnancy rates, multiple pregnancy rates, primary transfer rates and birth outcomes. MAIN RESULTS AND THE ROLE OF CHANCE: Over the 6 years of the CARTR Plus registry, the number of treatment cycles performed ranged from less than 200 to greater than 1000 per clinic. Patient age and the underlying cause of infertility were two of the most variable characteristics across clinics. Similar clinical pregnancy rates were found among IVF and frozen embryo transfer (FET) cycles with own oocytes (38.9 and 39.7% per embryo transfer cycle, respectively). Fertility treatment cycles that used donor oocytes had a higher clinical pregnancy rate among IVF cycles compared with FET cycles (54.9 and 39.8% per embryo transfer cycle, respectively). The multiple pregnancy rate was 7.4% per ongoing clinical pregnancy in 2018, which reflected a decreasing trend across the study period. Between 2013 and 2017, there were 31 811 pregnancies that had live births from all ART treatment cycles, which corresponded to a live birth rate of 21.4% per cycle start and 89.1% of these pregnancies were singleton live births. The low multiple pregnancy rate and high singleton birth rate are associated with the increase in single embryo transfers. LIMITATIONS REASONS FOR CAUTION: There is potential for misclassification of data, which is present in all administrative health databases. WIDER IMPLICATIONS OF THE FINDINGS: The CARTR Plus registry is a robust resource for ART data in Canada. It provides easily accessible aggregated data for Canadian fertility clinics, and it contains data that are internationally comparable. STUDY FUNDING/COMPETING INTERESTS: There was no funding provided for this study. The authors have no competing interests to declare.

Fetal macrosomia and adolescence obesity: results from a longitudinal cohort study.

OBJECTIVE: To assess the association between fetal macrosomia and adolescent obesity. DESIGN: Longitudinal cohort study of the association between macrosomia and adolescent obesity. SUBJECTS: Between 1 October 2005 and 1 February 2007, a follow-up study of live-born infants born in 1993-1995 in Wuxi, a suburban area of Shanghai, was conducted. Subjects with birth weight > 4000 g were selected as the exposed. For each exposed subject, one subject with a birth weight of 2500-4000 g, matched by year of birth, sex of infant, and type of institute at birth, was chosen as non-exposed. Clinical data were collected by structured interview and physical examination. Obesity was defined as body mass index (weight (kg)/height (m(2))) higher than the sex-age-specific criteria by the working group on obesity in China. Distribution of baseline characteristics and adolescent obesity rate between the exposed and non-exposed groups was compared. RESULTS: A total of 1435 pairs of exposed and non-exposed subjects were included in the final analysis. No major difference in baseline characteristics (other than birth weight) was found between the exposed and non-exposed groups. Obesity rate was significantly higher in the exposed group (2.9%) than in the non-exposed group (1.6%). Adolescent obesity rates were 1.4, 1.9, 2.6, and 5.6%, respectively, in study subjects with a birth weight of 2500-3499, 3500-3999, 4000-4499, and > or =4500 g. The association between birth weight and adolescent obesity remained essentially the same when mother's demographic and anthropometric factors, breast feeding, and adolescent life-style factors were adjusted. CONCLUSION: Compared with infants of normal birth weight, infants with birth weight >4000 g, especially those >4500 g, are at increased risk of adolescent obesity.

Comparison of maternal mortality between migrating population and permanent residents in Shanghai, China, 1996-2005.

OBJECTIVE: Maternal mortality ratio (MMR) in Shanghai residents has been declining in the past two decades and has reached levels comparable to developed countries. The MMR in migrating population in Shanghai remains high, however. The objectives of this study were to compare the trends of MMR between residents and migrating population in Shanghai from 1996 to 2005 and to explore the reasons for the dramatic differences in MMR between the two groups living in the same city. DESIGN: Retrospective cohort study. SETTING: Shanghai, China. POPULATION: A total of 902,807 pregnancies with live births in Shanghai in the period of 1996-2005. METHODS: We first compared the overall MMR between migrating population and permanent residents in Shanghai and examined temporal trends of MMR in the two subpopulations. We then compared the causes and maternal characteristics of maternal deaths between the two subpopulations. MAIN OUTCOME MEASURES: Maternal mortality and cause of death. RESULTS: A total of 902,807 live births and 243 maternal deaths were recorded in Shanghai in the period of 1996 to 2005, with an average MMR of 26.66 per 100,000 live births. The MMR in Shanghai residents declined dramatically from 22.47 per 100,000 in 1996 to 1.64 per 100,000 live births in 2005 (P < 0.01), while the MMR in migrating population was reduced only moderately from 54.68 per 100,000 live births to 48.46 per 100,000 (P > 0.05). The main causes of maternal deaths in migrating population were postpartum haemorrhage (39.9%), pregnancy-induced hypertension (9.8%), and puerperal infection (9.3%), whereas the main causes of maternal death of Shanghai residents were chronic heart and liver diseases (20.0%), postpartum haemorrhage (12.9%), and amniotic fluid embolism (12.9%). Among the maternal death cases in migrating women, 60% had elementary education or less, 22% were unemployed, 65% had no prenatal visit, 44% gave a birth at home, and 12% of the deaths occurred at home. CONCLUSION: Lack of access to quality maternity care, especially for the effective management of postpartum haemorrhage, is the main reason for the high MMR in migrating population in Shanghai.

The number of single nucleotide polymorphisms and on-farm data required for whole-herd parentage testing in dairy cattle herds.

New platforms utilizing single nucleotide polymorphisms (SNP) offer operational advantages over the conventional microsatellite-based ones, making them a promising alternative for parentage exclusion. Through simulation and empirical data, a 40-SNP panel (where the minor allele frequency was 0.35 on average) was shown to be a comparable or better diagnostic tool than the current 14-microsatellite panel that is used to parentage test New Zealand dairy animals. The 40 SNP alone did not have sufficient power of exclusion to match more than 75% of the progeny to the correct sire and dam. Utilizing mating records and grouping progeny and dams by birth and calving dates, respectively, decreased the number of sire-dam combinations that each progeny was tested against and dramatically increased the utility of the SNP. These results highlight the importance of combining genotypes with on-farm data to maximize the ability to assign parentage in the New Zealand dairy herd.

Monosynaptic GABAergic signaling from dentate to CA3 with a pharmacological and physiological profile typical of mossy fiber synapses.

Mossy fibers are the sole excitatory projection from dentate gyrus granule cells to the hippocampus, where they release glutamate, dynorphin, and zinc. In addition, mossy fiber terminals show intense immunoreactivity for the inhibitory neurotransmitter GABA. Fast inhibitory transmission at mossy fiber synapses, however, has not previously been reported. Here, we show that electrical or chemical stimuli that recruit dentate granule cells elicit monosynaptic GABA(A) receptor-mediated synaptic signals in CA3 pyramidal neurons. These inhibitory signals satisfy the criteria that distinguish mossy fiber-CA3 synapses: high sensitivity to metabotropic glutamate receptor agonists, facilitation during repetitive stimulation, and NMDA receptor-independent long-term potentiation. GABAergic transmission from the dentate gyrus to CA3 has major implications not only for information flow into the hippocampus but also for developmental and pathological processes involving the hippocampus.

Patterns of pregnancy exposure to prescription FDA C, D and X drugs in a Canadian population.

OBJECTIVE: To examine prescription Food and Drug Administration (FDA) C, D and X drugs in general obstetric population. STUDY DESIGN: Historical cohort study. RESULT: A total of 18 575 women who gave a birth in Saskatchewan between January 1997 and December 2000 were included. Among them, 3604 (19.4%) received FDA C, D or X drugs at least once during pregnancy. The pregnancy exposure rates were 15.8, 5.2 and 3.9%, respectively, for category C, D and X drugs, and were 11.2, 7.3 and 8.2%, respectively, in the first, second and third trimesters. Salbutamol (albuterol), trimethoprim/sulfamethoxazole (co-trimoxazole), ibuprofen, naproxen and oral contraceptives were the most common C, D, X drugs used during pregnancy. CONCLUSION: About one in every five women uses FDA C, D and X drugs at least once during pregnancy, and the most common prescription drugs in pregnancy are antiasthmatic, antibiotics, nonsteroid anti-inflammation drugs, antianxiety or antidepressants and oral contraceptives.

Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy.

OBJECTIVE: To quantify the risk of placenta praevia and placental abruption in singleton, second pregnancies after a caesarean delivery of the first pregnancy. DESIGN: Retrospective cohort study. SETTING: Linked birth and infant mortality database of the USA between 1995 and 2000. POPULATION: A total of 5,146,742 singleton second pregnancies were available for the final analysis after excluding missing information. METHODS: Multiple logistic regressions were used to describe the relationship between caesarean section at first birth and placenta praevia and placental abruption in second-birth singletons. MAIN OUTCOME MEASURES: Placenta praevia and placental abruption. RESULTS: Placenta praevia was recorded in 4.4 per 1000 second-birth singletons whose first births delivered by caesarean section and 2.7 per 1000 second-birth singletons whose first births delivered vaginally. About 6.8 per 1000 births were complicated with placental abruption in second-birth singletons whose first births delivered by caesarean section and 4.8 per 1000 birth in second-birth singletons whose first births delivered vaginally. The adjusted odds ratio (95% CIs) of previous caesarean section for placenta praevia in following second pregnancies was 1.47 (1.41, 1.52) after controlling for maternal age, race, education, marital status, maternal drinking and smoking during pregnancy, adequacy of prenatal care, and fetal gender. The corresponding figure for placental abruption was 1.40 (1.36, 1.45). CONCLUSION: Caesarean section for first live birth is associated with a 47% increased risk of placenta praevia and 40% increased risk of placental abruption in second pregnancy with a singleton.

Pregnancy-induced hypertension and infant mortality in triplets.

OBJECTIVE: To assess the effects of pregnancy-induced hypertension on infant mortality in triplets stratified by gestational age at birth. METHODS: A retrospective cohort study was conducted using the linked 1995-2000 US birth/infant death database. Generalized estimating equations were used to evaluate the observed association. RESULTS: Pregnancy-induced hypertension was associated with lesser neonatal mortality (odds ration [OR]: 0.34, 95% CI: 0.21, 0.54), postneonatal mortality (OR: 0.54, 95% CI: 0.30, 0.99) and infant mortality (OR, 0.37, 95% CI: 0.25, 0.55) in triplets. It was also associated with a decreased risk of neonatal death (OR, 0.38; 95% CI, 0.21-0.67), postneonatal death (OR, 0.45; 95% CI, 0.21-0.97), and infant death (OR, 0.39; 95% CI, 0.24-0.64) in early preterm triplets, whereas the association was not significant in late preterm or in full-term triplets. CONCLUSION: Pregnancy-induced hypertension is associated with a decreased risk of infant mortality in triplets. This effect varies with gestational age at birth.

A case of pure gelastic seizures due to hypothalamic hamartoma with a benign course.

Hypothalamic hamartoma is a potentially complex entity with diverse clinical manifestations. We report a case of gelastic seizures associated with a hypothalamic hamartoma, which followed a benign course. A 31-year-old woman with episodes of laughter was referred for diagnostic evaluation. Her initial MRI and EEG were reported as normal. However, her episodes of laughter were typical of gelastic seizures from history and video review. Repeat MRI revealed a small HH. She declined any medical treatment and was medication free until last follow-up. This benign course of HH-associated epilepsy, not necessitating treatment, to our knowledge, has not been previously reported.

Panic symptoms in transient loss of consciousness: Frequency and diagnostic value in psychogenic nonepileptic seizures, epilepsy and syncope.

PURPOSE: Previous studies suggest that ictal panic symptoms are common in patients with psychogenic nonepileptic seizures (PNES). This study investigates the frequency of panic symptoms in PNES and if panic symptoms, just before or during episodes, can help distinguish PNES from the other common causes of transient loss of consciousness (TLOC), syncope and epilepsy. METHODS: Patients with secure diagnoses of PNES (n=98), epilepsy (n=95) and syncope (n=100) were identified using clinical databases from three United Kingdom hospitals. Patients self-reported the frequency with which they experienced seven symptoms of panic disorder in association with their episodes. A composite panic symptom score was calculated on the basis of the frequency of symptoms. RESULTS: 8.2% of patients with PNES reported "never" experiencing any of the seven panic symptoms in their episodes of TLOC. Patients with PNES reported more frequent panic symptoms in their attacks than those with epilepsy (p<0.001) or syncope (p<0.001), however, patients with PNES were more likely "rarely" or "never" to report five of the seven-ictal panic symptoms than "frequently" or "always" (45-69% versus 13-29%). A receiver operating characteristic analysis demonstrated that the composite panic symptom score distinguished patients with PNES from the other groups (sensitivity 71.1%, specificity 71.2%), but not epilepsy from syncope. CONCLUSIONS: Patients with PNES report TLOC associated panic symptoms more commonly than those with epilepsy or syncope. Although panic symptoms are reported infrequently by most patients with PNES, a composite symptom score may contribute to the differentiation between PNES and the other two common causes of TLOC.