First-ever seizure and eligibility for commercial motor vehicle driving.

BACKGROUND: After a first-ever seizure, 6 months of seizure freedom is usually required before returning to driving a private motor vehicle, after which the annual risk of seizure recurrence has fallen to ≤20%. Stricter criteria apply for commercial driver's licence (CDL) holders, and a longer period of seizure freedom sufficient for the annual risk of recurrence to be <2% is recommended. However, CDL guidelines are based on little data with few studies having long-term follow-up. METHODS: 1714 patients with first-ever seizures were prospectively studied. Seizure recurrence was evaluated using survival analysis. The annual conditional risk of seizure recurrence was calculated for patients with first-ever unprovoked and acute symptomatic seizures, and according to the presence or absence of clinical, electroencephalogram (EEG) and neuroimaging risk factors for recurrence. RESULTS: The annual risk of recurrence for unprovoked first seizures did not fall below 2% until after 9 years of seizure freedom. The annual risk after 5 years of seizure freedom was still 3.9% (95% CI 1.8% to 6.1%) including for those without epileptiform abnormalities on EEG and with normal imaging. For acute symptomatic first seizures, the annual recurrence risk was 4.5% (95% CI 2.3% to 6.7%) after 1 year and fell below 2% only after 4 years of seizure freedom. CONCLUSIONS: For unprovoked and acute symptomatic first-ever seizure and CDL, a higher-than-expected annual seizure risk persists beyond the currently recommended seizure-free periods, even in those without risk factors for recurrence. Our data can inform decisions regarding a return to driving for CDL holders after first-ever seizure.

Long-term physical and psychiatric morbidities and mortality of untreated, deferred, and immediately treated epilepsy.

OBJECTIVE: In Australia, 30% of newly diagnosed epilepsy patients were not immediately treated at diagnosis. We explored health outcomes between patients receiving immediate, deferred, or no treatment, and compared them to the general population. METHODS: Adults with newly diagnosed epilepsy in Western Australia between 1999 and 2016 were linked with statewide health care data collections. Health care utilization, comorbidity, and mortality at up to 10 years postdiagnosis were compared between patients receiving immediate, deferred, and no treatment, as well as with age- and sex-matched population controls. RESULTS: Of 603 epilepsy patients (61% male, median age = 40 years) were included, 422 (70%) were treated immediately at diagnosis, 110 (18%) received deferred treatment, and 71 (12%) were untreated at the end of follow-up (median = 6.8 years). Immediately treated patients had a higher 10-year rate of all-cause admissions or emergency department presentations than the untreated (incidence rate ratio [IRR] = 2.0, 95% confidence interval [CI] = 1.4-2.9) and deferred treatment groups (IRR = 1.7, 95% CI = 1.0-2.8). They had similar 10-year risks of mortality and developing new physical and psychiatric comorbidities compared with the deferred and untreated groups. Compared to population controls, epilepsy patients had higher 10-year mortality (hazard ratio = 2.6, 95% CI = 2.1-3.3), hospital admissions (IRR = 2.3, 95% CI = 1.6-3.3), and psychiatric outpatient visits (IRR = 3.2, 95% CI = 1.6-6.3). Patients with epilepsy were also 2.5 (95% CI = 2.1-3.1) and 3.9 (95% CI = 2.6-5.8) times more likely to develop a new physical and psychiatric comorbidity, respectively. SIGNIFICANCE: Newly diagnosed epilepsy patients with deferred or no treatment did not have worse outcomes than those immediately treated. Instead, immediately treated patients had greater health care utilization, likely reflecting more severe underlying epilepsy etiology. Our findings emphasize the importance of individualizing epilepsy treatment and recognition and management of the significant comorbidities, particularly psychiatric, that ensue following a diagnosis of epilepsy.

First seizure while driving: Clinical features and prognosis.

OBJECTIVES: Patients with epilepsy are ineligible to drive until seizure free for an appropriate period given the risk of a seizure-related motor vehicle accident. Driving restrictions also apply to patients after their first-ever seizure. However, it is unclear whether a longer period of non-driving is required if the first seizure occurred while driving. The association of a seizure with driving may have been by chance or due to a specific factor or trigger increasing the likelihood of a seizure. More data is required to inform driving restrictions. METHODS: This study was based on prospectively collected data of consecutive adults with a first-ever seizure seen at a hospital-based first seizure clinic between 2000 and 2015. We examined the clinical, EEG and imaging features of patients who were eligible to drive, comparing patients with their first seizure while driving (FSWD) to those who had an awake first seizure at other times (FSOT) to explore possible differences clinical features and likelihood of seizure recurrence, evaluated using survival analysis. RESULTS: 57 patients with a FSWD were compared to 1335 patients with FSOT. 80 % of FSWD resulted in loss of control of the vehicle, 64 % with a crash and almost half of patients sustaining an injury. Fifty of 57 FSWD were related to an unprovoked first seizure. FSWD patients had a higher cumulative likelihood of having a second seizure than FSOT patients (50.1 % vs 36.2 % at 1 year, 57.9 % vs 41.7 % at 2 years and 65.1 % vs 47.8 % at 5 years; p = 0.003), with the conditional risk of seizure recurrence only falling consistently below 2.5 %/month at twelve months after the first seizure. Independent predictors of seizure recurrence on multivariable analysis were epileptogenic lesion on imaging, unprovoked (vs acute symptomatic) first seizure, epileptiform abnormality on EEG, focal seizure; and for those with unprovoked first seizure, FSWD and higher Rankin score were also predictors. CONCLUSIONS: First seizure whilst driving is an independent predictor of seizure recurrence for unprovoked seizures, supporting a longer period of seizure freedom before returning to driving.

Deformity, etiology, solution, sequence (DESS): Facial analysis in rhinoplasty.

PURPOSE: Rhinoplasty is amongst the most challenging surgeries to perfect and can take decades. This process begins during residency; however, residents often have limited exposure to rhinoplasty during their training and lack a standardized method for systematically analyzing and formulating a surgical plan. The DESS (Deformity, Etiology, Solution, Sequence) is a novel educational format for residents that serves to increase their pre-operative comfort with the surgical evaluation and intraoperative planning for a rhinoplasty. MATERIALS AND METHODS: A qualitative study performed at a tertiary academic institution with an otolaryngology residency program evaluating three consecutive residency classes comprised of four residents per class. A 9-item questionnaire was distributed to measure change in resident comfort after utilizing the DESS during their facial plastics rotation. Questionnaire responses highlighted resident comfort with facial nasal analysis, identifying deformities, suggesting surgical maneuvers, and synthesizing a comprehensive surgical plan. RESULTS: Ten of the twelve residents surveyed responded. Of those that responded, comfort in facial nasal analysis, identification of common nasal deformities, surgical planning, and development of an overall surgical plan were significantly improved after completion of the facial plastic rotation. These residents largely attributed their success to the systematic educational format, with an average score of 4.8/5.0 (SD 0.42). CONCLUSION: While rhinoplasty is a challenging artform to master, systematic approaches to analysis and operative planning are vital for teaching and guiding residents. Through this novel methodology, residents display significant improvement in their comfort with facial nasal analysis and overall surgical preparation.

Unraveling kinetic and synergistic effects during ultrasound-enhanced carbocatalysis for water remediation as a function of ultrasonic frequency.

The ability of the ultrasound (US) combined with peroxymonosulfate (PMS), and a carbonaceous material (BC) was evaluated in the degradation of a model pollutant (acetaminophen, ACE). The US/BC/PMS system was compared with other possible systems (US, oxidation by PMS, BC adsorption, BC/PMS, US/PMS, and US/BC. The effect of the ultrasonic frequency (40, 375, and 1135 kHz) on the kinetics and synergy of the ACE removal was evaluated. In the US system, kinetics was favored at 375 kHz due to the increased production of hydroxyl radicals (HO•), but this did not improve in the US/PMS and US/BC systems. However, synergistic and antagonistic effects were observed at the low and high frequencies where the production of radicals is less efficient but there is an activation of PMS through mechanical effects. US/BC/PMS at 40 kHz was the most efficient system obtaining ∼95% ACE removal (40 µM) in the first 10 min of treatment, and high synergy (S = 10.30). This was promoted by disaggregation of the carbonaceous material, increasing the availability of catalytic sites where PMS is activated. The coexistence of free-radical and non-radical pathways was analyzed. Singlet oxygen (1O2) played the dominant role in degradation, while HO• and sulfate radicals (SO4•-), scarcely generated at low frequency, play a minimum role. Performance in hospital wastewater (HWW), urine, and seawater (SW) evidenced the competition of organic matter by BC active sites and reactive species and the removal enhancement when Cl- is present. Besides, toxicity decreased by ∼20% after treatment, being the system effective after three cycles of reuse.

Intensifying the sonochemical degradation of hydrophilic organic contaminants by organic and inorganic additives.

The sonochemical system is highly effective at degrading hydrophobic substances but has limitations when it comes to eliminating hydrophilic compounds. This study examines the impact of organic and inorganic additives on improving the sonochemical degradation of hydrophilic pollutants in water. The effects of adding an organic substance (CCl4) and two inorganic ions (Fe2+ and HCO3-) were tested. The treatment was focused on a representative hydrophilic antibiotic, cefadroxil (CDX). Initially, the sonodegradation of CDX without additives was assessed and compared with two reference pollutants more hydrophobic than CDX: dicloxacillin (DCX) and methyl orange (MO). The results highlighted the limitations of ultrasound alone in degrading CDX. Subsequently, the impact of the additives on enhancing the removal of this recalcitrant pollutant was evaluated at two frequencies (375 and 990 kHz). A significant improvement in the CDX degradation was observed with the presence of CCl4 and Fe2+ at both frequencies. Increasing CCl4 concentration led to greater CDX elimination, whereas a high Fe2+ concentration had detrimental effects. To identify the reactive sites on CDX towards the species generated with the additives, theoretical calculations (i.e. Fukui indices and HOMO-LUMO gaps) were performed. These analyses indicated that the ß-lactam and dihydrothiazine rings on CDX are highly reactive towards oxidizing species. This research enhances our understanding of the relationship between the structural characteristics of contaminants and the sonochemical frequency in the action of additives having diverse nature.

First seizure from sleep: Clinical features and prognosis.

OBJECTIVES: Patients with a first-ever unprovoked seizure commonly have subsequent seizures and identifying predictors of recurrence has important management implications. Both prior brain insult and epileptiform abnormalities on electroencephalography (EEG) are established predictors of seizure recurrence. Some studies suggest that a first-ever seizure from sleep has a higher likelihood of recurrence. However, with relatively small numbers and inconsistent definitions, more data are required. METHODS: Prospective cohort study of adults with first-ever unprovoked seizure seen by a hospital-based first seizure service between 2000 and 2015. Clinical features and outcomes of first-ever seizure from sleep and while awake were compared. RESULTS: First-ever unprovoked seizure occurred during sleep in 298 of 1312 patients (23%), in whom the 1-year cumulative risk of recurrence was 56.9% (95% confidence interval [CI] 51.3-62.6) compared to 44.2% (95% CI 41.1-47.3, p < .0001) for patients with first-ever seizure while awake. First-ever seizure from sleep was an independent predictor of seizure recurrence, with a hazard ratio [HR] of 1.44 (95% CI 1.23-1.69), similar to epileptiform abnormalities on EEG (HR 1.48, 95% CI 1.24-1.76) and remote symptomatic etiology (HR 1.47, 95% CI 1.27-1.71). HR for recurrence in patients without either epileptiform abnormalities or remote symptomatic etiology was 1.97 (95% CI 1.60-2.44) for a sleep seizure compared to an awake seizure. For first seizure from sleep, 76% of second seizures also arose from sleep (p < .0001), with 65% of third seizures (p < .0001) also from sleep. Seizures from sleep were less likely to be associated with injury other than orolingual trauma, both with the presenting seizure (9.4% vs 30.6%, p < .0001) and first recurrence (7.5% vs 16.3%, p = .001). SIGNIFICANCE: First-ever unprovoked seizures from sleep are more likely to recur, independent of other risk factors, with recurrences also usually from sleep, and with a lower risk of seizure-related injury. These findings may inform treatment decisions and counseling after first-ever seizure.

Mortality after a first-ever unprovoked seizure.

OBJECTIVE: Although increased mortality associated with epilepsy is well understood, data in patients after their first-ever seizure are limited. We aimed to assess mortality after a first-ever unprovoked seizure and identify causes of death (CODs) and risk factors. METHODS: A prospective cohort study was undertaken of patients with first-ever unprovoked seizure between 1999 and 2015 in Western Australia. Two age-, gender-, and calendar year-matched local controls were obtained for each patient. Mortality data, including COD, based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes, were obtained. Final analysis was performed in January 2022. RESULTS: One thousand two hundred seventy-eight patients with a first-ever unprovoked seizure were compared to 2556 controls. Mean follow-up was 7.3 years (range = .1-20). Overall hazard ratio (HR) for death after a first unprovoked seizure compared to controls was 3.06 (95% confidence interval [CI] = 2.48-3.79), with HRs of 3.30 (95% CI = 2.26-4.82) for those without seizure recurrence and 3.21 (95% CI = 2.47-4.16) after a second seizure. Mortality was also increased in patients with normal imaging and no identified cause (HR = 2.50, 95% CI = 1.82-3.42). Multivariate predictors of mortality were increasing age, remote symptomatic causes, first seizure presentation with seizure cluster or status epilepticus, neurological disability, and antidepressant use at time of first seizure. Seizure recurrence did not influence mortality rate. The commonest CODs were neurological, most relating to the underlying cause of seizures rather than being seizure-related. Substance overdoses and suicide were more frequent CODs in patients compared to controls and were commoner than seizure-related deaths. SIGNIFICANCE: Mortality is increased two- to threefold after a first-ever unprovoked seizure, independent of seizure recurrence, and is not only attributable to the underlying neurological etiology. The greater likelihood of deaths related to substance overdose and suicide highlights the importance of assessing psychiatric comorbidity and substance use in patients with first-ever unprovoked seizure.

Acute and chronic kidney injury during therapy for pediatric acute leukemia: A report from the Leukemia Electronic Abstraction of Records Network (LEARN).

Children with acute leukemia are at increased risk of kidney injury. Using electronic health record data from three centers between 2010 and 2018, this study retrospectively described acute kidney injury (AKI) and chronic kidney disease (CKD) prevalence in children with acute lymphoblastic or myeloid leukemia (ALL, AML) using Common Terminology Criteria for Adverse Events (CTCAE) and Kidney Disease Improving Global Outcomes (KDIGO) definitions. AKI during therapy was 25% (ALL) and 32% (AML) using CTCAE, versus 84% (ALL) and 74% (AML) using KDIGO. CKD prevalence was low and Grade 1/Stage 2. Further investigation is needed to optimally define kidney injury in acute leukemia.

Possibilities and Limitations of the Sono-Fenton Process Using Mid-High-Frequency Ultrasound for the Degradation of Organic Pollutants.

Mid-high-frequency ultrasound (200-1000 kHz) eliminates organic pollutants and also generates H2O2. To take advantage of H2O2, iron species can be added, generating a hybrid sono-Fenton process (sF). This paper presents the possibilities and limitations of sF. Heterogeneous (a natural mineral) and homogeneous (Fe2+ and Fe3+ ions) iron sources were considered. Acetaminophen, ciprofloxacin, and methyl orange were the target organic pollutants. Ultrasound alone induced the pollutants degradation, and the dual competing role of the natural mineral (0.02-0.20 g L-1) meant that it had no significant effects on the elimination of pollutants. In contrast, both Fe2+ and Fe3+ ions enhanced the pollutants' degradation, and the elimination using Fe2+ was better because of its higher reactivity toward H2O2. However, the enhancement decreased at high Fe2+ concentrations (e.g., 5 mg L-1) because of scavenger effects. The Fe2+ addition significantly accelerated the elimination of acetaminophen and methyl orange. For ciprofloxacin, at short treatment times, the degradation was enhanced, but the pollutant complexation with Fe3+ that came from the Fenton reaction caused degradation to stop. Additionally, sF did not decrease the antimicrobial activity associated with ciprofloxacin, whereas ultrasound alone did. Therefore, the chemical structure of the pollutant plays a crucial role in the feasibility of the sF process.

Risk factors and consequences of self-discontinuation of treatment by patients with newly diagnosed epilepsy.

OBJECTIVE: Patients with epilepsy not uncommonly self-discontinue treatment with antiseizure medications (ASM). The rate, reasons for this, and consequences have not been well studied. METHODS: We analyzed self-discontinuation of ASM treatment in patients with recently diagnosed epilepsy via review of clinic letters and hospital correspondence in a prospective cohort of first seizure patients. RESULTS: We studied 489 patients with newly diagnosed and treated epilepsy (median age 41, range 14-88, 62% male), followed up for a median duration of 3.0 years (interquartile range [IQR]: 1.2-6.0). Seventy eight (16.0%) self-discontinued ASM therapy after a median treatment duration of 1.4 years (IQR: 0.4-2.9), and after a median duration of seizure freedom of 11.8 months (IQR: 4.6-31.8). Patients commonly self-discontinued treatment due to adverse effects (41%), perception that treatment was no longer required (35%), and planned or current pregnancy (12%). Patients who self-discontinued were less likely to have epileptogenic lesions on neuroimaging (hazard ratio [HR] = 0.44, 95% confidence interval [CI]: 0.23-0.83), presentation with seizure clusters (HR = 0.32, 95% CI: 0.14-0.69) and presentation with tonic-clonic seizures (HR = 0.36, 95% CI: 0.19-0.70). Patients with shorter interval since the last seizure (HR = 0.76, 95% CI: 0.66-0.86) were more likely to self-discontinue treatment. Sleep deprivation prior to seizures before diagnosis (HR = 1.80, 95% CI: 1.05-3.09) and significant alcohol or illicit drug use (HR = 2.35, 95% CI: 1.20-4.59) were also associated with higher rates of discontinuation. After discontinuation, 51 patients (65%) experienced seizure recurrence, and 43 (84%) restarted treatment. Twenty two patients (28%) experienced a seizure-related injury after treatment discontinuation. SIGNIFICANCE: Self-initiated discontinuation of ASM treatment was not uncommon in patients with newly treated epilepsy. Reasons for discontinuation highlight areas for improved discussion with patients, including the chronicity of epilepsy and management strategies for current or potential adverse effects.

Short- and long-term outcomes of immediate and delayed treatment in epilepsy diagnosed after one or multiple seizures.

OBJECTIVES: To compare the outcomes between immediate and deferred treatments in patients diagnosed after one or multiple (two or more) seizures. METHODS: Our observational study investigated seizure recurrence and 12-month seizure remission in patients with newly diagnosed epilepsy, comparing immediate to deferred treatment in patients diagnosed after one seizure or after two or more seizures. RESULTS: Of 598 patients (62% male, median age 39 years), 347 (58%) were treated at diagnosis and 251 (42%) received deferred or no treatment. Seizure recurrence was higher with deferred treatment both in patients diagnosed after two or more seizures (n = 363; adjusted hazard ratio [aHR] = 2.38, 95% confidence interval [CI]: 1.79-3.14, p < 0.001) and after one seizure (n = 235; aHR = 1.41, 95% CI: 0.995-1.99, p = 0.05). Cumulative seizure recurrence rates at two years in patients diagnosed after two or more seizures were 73% with deferred treatment and 49% with immediate treatment (risk-factor-corrected number-needed-to-treat [NNT] = 4), and in those diagnosed after one seizure the rates were 60% and 51% (NNT = 8). Of 380 patients with eligible follow-up (median 4.3 years), 287 (76%) had been in seizure remission for at least one year and 211 (56%) remained in remission at last follow-up. Long-term remission rates were similar between immediate and deferred treatments, and between patients diagnosed after one seizure and those with two or more seizures. SIGNIFICANCE: Immediate rather than deferred treatment was less likely to influence seizure recurrence in patients diagnosed with epilepsy after a single seizure than in those diagnosed after two or more seizures, and showed no differences in long-term seizure freedom.

The role of ozone combined with UVC/H2O2 process for the tertiary treatment of a real slaughterhouse wastewater.

The main goal of this work is to evaluate the usage of ozone (O3) as a pre-treatment or simultaneously combined with UVC/H2O2 process for the polishing stage treatment of real bio-treated slaughterhouse wastewater. Two different treatment strategies were tested: i) pre-ozonation of the wastewater followed by an UVC/H2O2 process (two-step treatment); ii) simultaneous application of O3/UVC/H2O2 combined process (one-step treatment). For the two-step strategy, the pre-treatment with 30 mg O3/min for 10 min reduces significantly total suspended solids (TSS), turbidity and colour, reducing light filtering effects and increasing the efficiency of the following UVC/H2O2 process. In turn, the one-step treatment strategy (O3/UVC/H2O2) allows a more efficient use of injected O3 by reducing the amount of O3 required (from 273 to 189 mg O3/Leffluent) to achieve similar mineralization levels. The real bio-treated slaughterhouse wastewater treated by O3/UVC/H2O2 process achieved final colour values of 20 Pt/Co, TSS of 35 mg/L and COD of 61 mg O2/L, allowing its direct discharge into water compartments according to European Council Directive 91/271/EEC.

Empowering families facing end-stage nonmalignant chronic diseases with a holistic, transdisciplinary, community-based intervention: 3 months outcome of the Life Rainbow Program.

OBJECTIVES: Families facing end-stage nonmalignant chronic diseases (NMCDs) are presented with similar symptom burdens and need for psycho-social-spiritual support as their counterparts with advanced cancers. However, NMCD patients tend to face more variable disease trajectories, and thus may require different anticipatory supports, delivered in familiar environments. The Life Rainbow Programme (LRP) provides holistic, transdisciplinary, community-based end-of-life care for patients with NMCDs and their caregivers. This paper reports on the 3-month outcomes using a single-group, pre-post comparison. METHOD: Patients with end-stage NMCDs were screened for eligibility by a medical team before being referred to the LRP. Patients were assessed at baseline (T0), 1 month (T1), and 3 months (T2) using the Integrated Palliative Outcome Scale (IPOS). Their hospital use in the previous month was also measured by presentations at accident and emergency services, admissions to intensive care units, and number of hospital bed-days. Caregivers were assessed at T0 and T2 using the Chinese version of the Modified Caregiver Strain Index, and self-reported health, psychological, spiritual, and overall well-being. Over-time changes in outcomes for patients, and caregivers, were tested using paired-sample t-tests, Wilcoxon-signed rank tests, and chi-square tests. RESULTS: Seventy-four patients and 36 caregivers participated in this research study. Patients reported significant improvements in all IPOS domains at both 1 and 3 months [ranging from Cohen's d = 0.495 (nausea) to 1.793 (depression and information needs fulfilled)]. Average hospital bed-days in the previous month fell from 3.50 to 1.68, comparing baseline and 1 month (p < 0.05). At 3 months, caregiver strain was significantly reduced (r = 0.332), while spiritual well-being was enhanced (r = 0.333). SIGNIFICANCE: After receiving 3 month's LRP services, patients with end-stage NMCDs and their caregivers experienced significant improvements in the quality of life and well-being, and their hospital bed-days were reduced.

Treatment initiation decisions in newly diagnosed epilepsy-A longitudinal cohort study.

OBJECTIVE: To examine the factors and reasons influencing treatment initiation decisions in patients with newly diagnosed epilepsy. METHODS: We assessed antiseizure medication initiation decisions in adults with newly diagnosed epilepsy seen at first seizure clinics in Western Australia between 1999 and 2016 and followed to 2018. RESULTS: Of 610 patients (median age 40 years, 61.0% male), 426 (69.8%) were diagnosed after two or more seizures and 184 (30.2%) after a single seizure with risk factors for recurrence. Treatment was commenced in 427 patients (70.0%) at diagnosis, 112 (18.4%) during follow-up, mostly after further seizures, whereas 71 (11.6%) remained untreated at last follow-up. Elders (≥65 years, odds ratio [OR] = 3.06, 95% confidence interval [CI]: 1.62-5.80), more seizures (OR = 3.48, 95% CI: 2.03-5.96), and epileptogenic lesions on neuroimaging (OR = 2.15, 95% CI: 1.26-3.68) had a higher likelihood of treatment at diagnosis. Patients with less than one seizure per year within the preceding year (OR = 0.40, 95% CI: 0.21-0.73) and of higher socioeconomic status (OR = 0.985, 95% CI: 0.977-0.994) were less likely to be treated. For 93 patients (15.2%), treatment was not recommended at diagnosis, most commonly because only a single seizure had occurred. Ninety patients (14.8%) declined recommended treatment, mostly because they were unconvinced of the need for treatment or the diagnosis. SIGNIFICANCE: Thirty percent of adults with newly diagnosed epilepsy were not immediately treated. Treatment initiation in this real-world cohort was influenced by age, number of seizures prior to diagnosis, imaging findings, patient preferences, and socioeconomic status.

The other side of the leaf: Seizures associated with synthetic cannabinoid use.

There has recently been a marked rise in the medicinal use of cannabis for epilepsy and multiple other conditions. While seizures have been reported in association with synthetic cannabinoids, the clinical features and prognosis have not been studied. Thirty patients with a history of seizures occurring within 24 h of synthetic cannabinoid use were identified from a first seizure clinic database in Perth, Western Australia between 2011 and 2016. Eight had a prior history of seizures, three related to synthetic cannabinoid use, with an additional three patients having risk factors for seizures. The presenting event was a tonic-clonic seizure in 27 patients (90%). "Kronic" was the synthetic cannabinoid used by 16 patients. Absorption was via smoking in all cases, with seizures occurring within 30 min of inhalation in 14 patients (46%). Electroencephalography (EEG) showed epileptiform abnormalities in 11%, and neuroimaging revealed epileptogenic lesions in 12%. Nine of 24 patients with follow-up had subsequent seizures, occurring in the setting of further synthetic cannabinoid use in two patients. This seizure recurrence rate is similar to seizures provoked by other acute systemic insults. In conclusion, smoking of some synthetic cannabinoids is associated with seizures, and this may relate to an intrinsic proconvulsant effect.

Pharmacy intervention to facilitate transparent opioid-risk and safety communication.

OBJECTIVE: This paper seeks to explore the impact of training, a handout, and patients' questions on pharmacists' comfort and satisfaction in discussing opioid risks with pediatric caregivers. METHODS: In a mixed methods intervention study in a children's hospital outpatient pharmacy, 2 practicing pharmacists and 1 student pharmacist counseled 100 caregivers using their standard practices (not telling a caregiver the pain medicine was an opioid or informing them about opioid risks). After the training, the same 2 pharmacists and another student pharmacist counseled 97 caregivers about opioid-risk by assessing their beliefs, explaining that the medication was an "opioid," and integrating a safety handout into the consult. The pharmacists completed short surveys after each consult in both phases and were interviewed. Qualitative data were coded using NVivo version 12 (QSR International). Descriptive statistics and multivariate regression analyses were performed on the data collected from the surveys. RESULTS: During the preintervention phase, opioid risks were not discussed; no pharmacist described the pain medication as an opioid. The pharmacists reported that they needed training and resources to assist opioid counseling. In the postintervention phase, the pharmacists indicated that the medication was an opioid in all consults. The pharmacists' comfort increased significantly over time and decreased with caregivers' concerns at posttest (adjusted R2 = 0.40). The pharmacists' satisfaction increased with time and caregiver questions (adjusted R2 = 0.15). The pharmacists reported that the training and handout facilitated opioid-risk and safety discussions. CONCLUSION: The intervention positively affected pharmacists' comfort and satisfaction. It should be evaluated in different settings and populations.

Improving Provider Readiness for Intimate Partner Violence Screening.

BACKGROUND: Intimate partner violence (IPV) is a significant public health issue. Healthcare providers (e.g., nurses, advanced practice nurses, physicians, social workers) have a unique opportunity to prevent and reduce IPV through screening and referral. The objective of this project was to determine the impact of education and a brief screening tool integrated into the electronic medical record (EMR) on readiness to screen for IPV. METHODS: An intervention was implemented that included the EMR integration of a screening tool, creation of an automated resource telephone system and healthcare provider IPV screening and response education. Readiness for screening was evaluated pre- and postintervention using the Domestic Violence Health Care Provider Survey Scale (DVHCPSS), which is scored cumulatively and by each of six domains. An unpaired Student's t test was performed. RESULTS: Mean age (31-40 years of age) and years of clinical practice (11-15 years) was the same for pre- (n = 96) and postintervention (n = 83) survey respondents. There was an overall significant increase in screening readiness (p = .003) with significant improvement in "professional role resistance/fear of offending the patient" (p < .0001), "blame victim items" (p = .0029), "perceived self-efficacy" (p = .0064), and "victim/provider safety" (p = .003). LINKING EVIDENCE TO ACTION: Adopting and integrating a validated IPV screening tool into the EMR combined with education was associated with an improvement in overall readiness for IPV screening. Reducing and preventing IPV through universal screening and referral can be accomplished by embedding a standardized readily accessible validated IPV screening tool in the EMR.

Is the first seizure epilepsy--and when?

OBJECTIVE: Epilepsy has recently been redefined to include a single unprovoked seizure if the probability of recurrence is ≥60% over the following 10 years. This definition is based on the estimated risk of a third seizure after two unprovoked seizures, using the lower-limit 95% confidence interval (CI) at 4 years, and does not account for the initially high recurrence rate after first-ever seizure that rapidly falls with increasing duration of seizure freedom. We analyzed long-term outcomes after the first-ever seizure, and the influence of duration of seizure freedom on the likelihood of seizure recurrence, and their relevance to the new definition of epilepsy. METHODS: Prospective analysis of 798 adults with a first-ever unprovoked seizure seen at a hospital-based first seizure clinic between 2000 and 2011. The likelihood of seizure recurrence was analyzed according to the duration of seizure freedom, etiology, electroencephalography (EEG), and neuroimaging findings. RESULTS: The likelihood of seizure recurrence at 10 years was ≥60% in patients with epileptiform abnormalities on EEG or neuroimaging abnormalities, therefore, meeting the new definition of epilepsy. However, the risk of recurrence was highly time dependent; after a brief period (≤12 weeks) of seizure freedom, no patient group continued to fulfill the new definition of epilepsy. Of 407 patients who had a second seizure, the likelihood of a third seizure at 4 years was 68% (95% CI 63-73%) and at 10 years was 85% (95% CI 79-91%). SIGNIFICANCE: The duration of seizure freedom following first-ever seizure substantially influences the risk of recurrence, with none of our patients fulfilling the new definition of epilepsy after a short period of seizure freedom. When a threshold was applied based on the 10-year risk of a third seizure from our data, no first-seizure patient group ever had epilepsy. These data may be utilized in a definition of epilepsy after a first-ever seizure.