Hawks and Doves: Perceptions and Reality of Faculty Evaluations.

OBJECTIVES: Internal medicine clerkship grades are important for residency selection, but inconsistencies between evaluator ratings threaten their ability to accurately represent student performance and perceived fairness. Clerkship grading committees are recommended as best practice, but the mechanisms by which they promote accuracy and fairness are not certain. The ability of a committee to reliably assess and account for grading stringency of individual evaluators has not been previously studied. METHODS: This is a retrospective analysis of evaluations completed by faculty considered to be stringent, lenient, or neutral graders by members of a grading committee of a single medical college. Faculty evaluations were assessed for differences in ratings on individual skills and recommendations for final grade between perceived stringency categories. Logistic regression was used to determine if actual assigned ratings varied based on perceived faculty's grading stringency category. RESULTS: "Easy graders" consistently had the highest probability of awarding an above-average rating, and "hard graders" consistently had the lowest probability of awarding an above-average rating, though this finding only reached statistical significance only for 2 of 8 questions on the evaluation form (P = .033 and P = .001). Odds ratios of assigning a higher final suggested grade followed the expected pattern (higher for "easy" and "neutral" compared to "hard," higher for "easy" compared to "neutral") but did not reach statistical significance. CONCLUSIONS: Perceived differences in faculty grading stringency have basis in reality for clerkship evaluation elements. However, final grades recommended by faculty perceived as "stringent" or "lenient" did not differ. Perceptions of "hawks" and "doves" are not just lore but may not have implications for students' final grades. Continued research to describe the "hawk and dove effect" will be crucial to enable assessment of local grading variation and empower local educational leadership to correct, but not overcorrect, for this effect to maintain fairness in student evaluations.

Detection of brain somatic mutations in focal cortical dysplasia during epilepsy presurgical workup.

Brain-restricted somatic variants in genes of the mechanistic target of rapamycin signalling pathway cause focal epilepsies associated with focal cortical dysplasia type II. We hypothesized that somatic variants could be identified from trace tissue adherent to explanted stereoelectroencephalography electrodes used in the presurgical epilepsy workup to localize the epileptogenic zone. We investigated three paediatric patients with drug-resistant focal epilepsy subjected to neurosurgery. In the resected brain tissue, we identified low-level mosaic somatic mutations in AKT3 and DEPDC5 genes. We collected stereoelectroencephalography depth electrodes in the context of a second presurgical evaluation and identified 4/33 mutation-positive electrodes that were either located in the epileptogenic zone or at the border of the dysplasia. We provide the proof-of-concept that somatic mutations with low levels of mosaicism can be detected from individual stereoelectroencephalography electrodes and support a link between the mutation load and the epileptic activity. Our findings emphasize future opportunities for integrating genetic testing from stereoelectroencephalography electrodes into the presurgical evaluation of refractory epilepsy patients with focal cortical dysplasia type II to improve the patients' diagnostic journey and guide towards precision medicine.

Adaptation of the WOMAC for Use in a Patient Preference Study.

OBJECTIVES: To adapt a patient-reported outcome (PRO) measure, the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), into efficacy attributes for a discrete choice experiment (DCE) survey designed to quantify the relative importance of endpoints commonly used in knee osteoarthritis (KOA) trials. METHODS: The adaptation comprised four steps: (1) selecting domains of interest; (2) determining presentation and framing of selected attributes; (3) determining attribute levels; and (4) developing choice tasks. This process involved input from multiple stakeholders, including regulators, health preference researchers, and patients. Pretesting was conducted to evaluate if patients comprehended the adapted survey attributes and could make trade-offs among them. RESULTS: The WOMAC pain and function domains were selected for adaption to two efficacy attributes. Two versions of the discrete choice experiment (DCE) instrument were created to compare efficacy using (1) total domain scores and (2) item scores for "walking on a flat surface." Both attributes were presented as improvement from baseline scores by levels of 0%, 30%, 50%, and 100%. Twenty-six participants were interviewed in a pretest of the instrument (average age 60 years; 58% female; 62% had KOA for ≥ 5 years). The participants found both versions of attributes meaningful and relevant for treatment decision-making. They demonstrated willingness and ability to tradeoff improvements in pain and function separately, though many perceived them as inter-related. CONCLUSIONS: This study adds to the growing literature regarding adapting PRO measures for patient preference studies. Such adaptation is important for designing a preference study that can incorporate a clinical trial's outcomes with PRO endpoints.

'Women in the front': Psychological impact of the COVID-19 pandemic: Depression, anxiety, loneliness, and somatization in the Israel population.

The COVID-19 pandemic has generated a high level of psychological distress in the general population. The aims of this study were to examine the mental health of men and women in the general population in Israel during the first lockdown. The sample comprised 587 participants (426 females and 161 males), whose age ranged between 16 and 85. They completed the Patient Health Questionnaire-4 (PHQ-4), the Psychosomatic Symptoms Scale, and the Connor-Davidson Resilience Scale (CD-RISC2). Psychological distress was expressed in our measures of depression, anxiety, loneliness, and somatization, in conjunction with high resilience. Women exhibited higher levels of these symptoms than men-but this fluctuates with age, and can match the levels of these symptoms reported by men. Specifically, no difference between the genders was found for loneliness, in age groups 24-39 and 56-85; and for depression, in age groups 40-55 and 56-85. For somatization, the difference is reversed for age group 56-85. In contrast, while women generally scored lower than the men for resilience, this was specifically for age group 16-23. Our findings suggest that young women report more mental health problems, and that men and women may be differentially vulnerable to disaster-related stressors, such as experienced during the pandemic.

A Versatile and Scalable Platform That Streamlines Data Collection for Patient-Centered Studies: Usability and Feasibility Study.

BACKGROUND: The Food and Drug Administration Center for Biologics Evaluation and Research (CBER) established the Biologics Effectiveness and Safety (BEST) Initiative with several objectives, including the expansion and enhancement of CBER's access to fit-for-purpose data sources, analytics, tools, and infrastructures to improve the understanding of patient experiences with conditions related to CBER-regulated products. Owing to existing challenges in data collection, especially for rare disease research, CBER recognized the need for a comprehensive platform where study coordinators can engage with study participants and design and deploy studies while patients or caregivers could enroll, consent, and securely participate as well. OBJECTIVE: This study aimed to increase awareness and describe the design, development, and novelty of the Survey of Health and Patient Experience (SHAPE) platform, its functionality and application, quality improvement efforts, open-source availability, and plans for enhancement. METHODS: SHAPE is hosted in a Google Cloud environment and comprises 3 parts: the administrator application, participant app, and application programming interface. The administrator can build a study comprising a set of questionnaires and self-report entries through the app. Once the study is deployed, the participant can access the app, consent to the study, and complete its components. To build SHAPE to be scalable and flexible, we leveraged the open-source software development kit, Ionic Framework. This enabled the building and deploying of apps across platforms, including iOS, Android, and progressive web applications, from a single codebase by using standardized web technologies. SHAPE has been integrated with a leading Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) application programming interface platform, 1upHealth, which allows participants to consent to 1-time data pull of their electronic health records. We used an agile-based process that engaged multiple stakeholders in SHAPE's design and development. RESULTS: SHAPE allows study coordinators to plan, develop, and deploy questionnaires to obtain important end points directly from patients or caregivers. Electronic health record integration enables access to patient health records, which can validate and enhance the accuracy of data-capture methods. The administrator can then download the study data into HL7® FHIR®-formatted JSON files. In this paper, we illustrate how study coordinators can use SHAPE to design patient-centered studies. We demonstrate its broad applicability through a hypothetical type 1 diabetes cohort study and an ongoing pilot study on metachromatic leukodystrophy to implement best practices for designing a regulatory-grade natural history study for rare diseases. CONCLUSIONS: SHAPE is an intuitive and comprehensive data-collection tool for a variety of clinical studies. Further customization of this versatile and scalable platform allows for multiple use cases. SHAPE can capture patient perspectives and clinical data, thereby providing regulators, clinicians, researchers, and patient advocacy organizations with data to inform drug development and improve patient outcomes.

Gender Disparity in Evaluation of Internal Medicine Clerkship Performance.

Importance: Women studying medicine currently equal men in number, but evidence suggests that men and women might not be evaluated equally throughout their education. Objective: To examine whether there are differences associated with gender in either objective or subjective evaluations of medical students in an internal medicine clerkship. Design, Setting, and Participants: This single-center retrospective cohort study evaluated data from 277 third-year medical students completing internal medicine clerkships in the 2017 to 2018 academic year at an academic hospital and its affiliates in Pennsylvania. Data were analyzed from September to November 2020. Exposure: Gender, presumed based on pronouns used in evaluations. Main Outcomes and Measures: Likert scale evaluations of clinical skills, standardized examination scores, and written evaluations were analyzed. Univariate and multivariate linear regression were used to observe trends in measures. Word embeddings were analyzed for narrative evaluations. Results: Analyses of 277 third-year medical students completing an internal medicine clerkship (140 women [51%] with a mean [SD] age of 25.5 [2.3] years and 137 [49%] presumed men with a mean [SD] age of 25.9 [2.7] years) detected no difference in final grade distribution. However, women outperformed men in 5 of 8 domains of clinical performance, including patient interaction (difference, 0.07 [95% CI, 0.04-0.13]), growth mindset (difference, 0.08 [95% CI, 0.01-0.11]), communication (difference, 0.05 [95% CI, 0-0.12]), compassion (difference, 0.125 [95% CI, 0.03-0.11]), and professionalism (difference, 0.07 [95% CI, 0-0.11]). With no difference in examination scores or subjective knowledge evaluation, there was a positive correlation between these variables for both genders (women: r = 0.35; men: r = 0.26) but different elevations for the line of best fit (P < .001). Multivariate regression analyses revealed associations between final grade and patient interaction (women: coefficient, 6.64 [95% CI, 2.16-11.12]; P = .004; men: coefficient, 7.11 [95% CI, 2.94-11.28]; P < .001), subjective knowledge evaluation (women: coefficient, 6.66 [95% CI, 3.87-9.45]; P < .001; men: coefficient, 5.45 [95% CI, 2.43-8.43]; P < .001), reported time spent with the student (women: coefficient, 5.35 [95% CI, 2.62-8.08]; P < .001; men: coefficient, 3.65 [95% CI, 0.83-6.47]; P = .01), and communication (women: coefficient, 6.32 [95% CI, 3.12-9.51]; P < .001; men: coefficient, 4.21 [95% CI, 0.92-7.49]; P = .01). The model based on the men's data also included growth mindset as a significant variable (coefficient, 4.09 [95% CI, 0.67-7.50]; P = .02). For narrative evaluations, words in context with "he or him" and "she or her" differed, with agentic terms used in descriptions of men and personality descriptors used more often for women. Conclusions and Relevance: Despite no difference in final grade, women scored higher than men on various domains of clinical performance, and performance in these domains was associated with evaluators' suggested final grade. The content of narrative evaluations significantly differed by student gender. This work supports the hypothesis that how students are evaluated in clinical clerkships is associated with gender.

Vertical parasagittal hemispherotomy: a case report of postoperative mesio-temporal seizures via amygdalofugal pathway.

Vertical parasagittal hemispherotomy (VPH) is a well-established surgical treatment which is proposed for children with widespread unilateral onset of intractable epileptic seizures. VPH allows to disconnect from a vertical transventricular approach all white matter fibers of the hemisphere around a central core including the thalamus. We present the case of a girl who underwent VPH for hemimegalencephaly in early infancy. Postoperatively, she developed unexpected seizures of mesio-temporal origin. Stereo-EEG provided arguments for an amygdalar origin. High-resolution MRI with tractography confirmed the presence of the amygdalo-fugal pathway to be responsible of epileptic discharges propagation. She became seizure-free after temporal resection.

[Content Themes and Influential Voices Within Vaccine Opposition on Twitter, 2019]. / Temas de contenido y voces influyentes dentro de la oposición a las vacunas en Twitter, 2019.

OBJECTIVES: To report on vaccine opposition and misinformation promoted on Twitter, highlighting Twitter accounts that drive conversation. METHODS: We used supervised machine learning to code all Twitter posts. We first identified codes and themes manually by using a grounded theoretical approach and then applied them to the full data set algorithmically. We identified the top 50 authors month-over-month to determine influential sources of information related to vaccine opposition. RESULTS: The data collection period was June 1 to December 1, 2019, resulting in 356 594 mentions of vaccine opposition. A total of 129 Twitter authors met the qualification of a top author in at least 1 month. Top authors were responsible for 59.5% of vaccine-opposition messages. We identified 10 conversation themes. Themes were similarly distributed across top authors and all other authors mentioning vaccine opposition. Top authors appeared to be highly coordinated in their promotion of misinformation within themes. CONCLUSIONS: Public health has struggled to respond to vaccine misinformation. Results indicate that sources of vaccine misinformation are not as heterogeneous or distributed as it may first appear given the volume of messages. There are identifiable upstream sources of misinformation, which may aid in countermessaging and public health surveillance.

Building Strong Futures: The Feasibility of Using a Targeted Digital Media Campaign to Improve Knowledge About Pregnancy and Low Birthweight Among Black Women.

OBJECTIVE: Low birthweight is one of the main causes of poor health outcomes among newborns, with Black women having a disproportionately high prevalence. A digital intervention targeted Black women in Orange County, Florida with information on positive pregnancy-related knowledge and attitudes related to low birthweight. This paper reports on campaign methods for the first 2.5 years of implementation. METHODS: Campaign content was tailored toward Black women, around a reproductive empowerment lens. Content focused on emphasizing healthy pregnancy-related behaviors and creating positive representations of Black women throughout the various stages of pregnancy through both static images and a web series. Digital metrics gauged campaign engagement. Three cross-sectional online surveys conducted in the intervention county examined Black women's pregnancy-related knowledge, attitudes, and behaviors. RESULTS: After two years of campaign implementation, social media accounts showed 1784 followers. While Facebook showed more average monthly impressions, Instagram showed more average monthly engagements. Survey results showed some increases in knowledge about prenatal care, weight gain, exercise, and the health impacts of low birthweight. CONCLUSIONS FOR PRACTICE: This study highlights the potential for a culturally-appropriate digital intervention to promote positive pregnancy outcomes among at-risk women. Digital interventions offer a potential way to achieve positive pregnancy-related behavior changes on a larger scale. This may be particularly important given that the COVID-19 pandemic may be changing the ways that pregnant women access information. Studies should examine the impact and feasibility of using culturally-appropriate digital interventions that directly address Black women and their specific experiences during pregnancy.

Temas de contenido y voces influyentes dentro de la oposición a las vacunas en Twitter, 2019 / Content Themes and Influential Voices Within Vaccine Opposition on Twitter, 2019

RESUMEN Objetivo. Informar sobre la oposición a las vacunas y la información errónea fomentadas en Twitter, destacando las cuentas de Twitter que dirigen estas conversaciones. Métodos. Utilizamos el aprendizaje automático supervisado para codificar todos los mensajes publicados en Twitter. En primer lugar, identificamos manualmente los códigos y los temas mediante un enfoque teórico fundamentado y, a continuación, los aplicamos a todo el conjunto de datos de forma algorítmica. Identificamos a los 50 autores más importantes un mes tras otro para determinar las fuentes influyentes de información relacionadas con la oposición a las vacunas. Resultados. El período de recopilación de datos fue del 1 de junio al 1 de diciembre del 2019, lo que dio lugar a 356 594 mensajes opuestos a las vacunas. Un total de 129 autores de Twitter reunieron los criterios de autor principal durante al menos un mes. Los autores principales fueron responsables del 59,5% de los mensajes opuestos a las vacunas y detectamos diez temas de conversación. Los temas se distribuyeron de forma similar entre los autores principales y todos los demás autores que declararon su oposición a las vacunas. Los autores principales parecían estar muy coordinados en su promoción de la información errónea sobre cada tema. Conclusiones. La salud pública se ha esforzado por responder a la información errónea sobre las vacunas. Los resultados indican que las fuentes de información errónea sobre las vacunas no son tan heterogéneas ni están tan distribuidas como podría parecer a primera vista, dado el volumen de mensajes. Existen fuentes identificables de información errónea, lo que puede ayudar a contrarrestar los mensajes y a fortalecer la vigilancia de la salud pública.

ABSTRACT Objectives. To report on vaccine opposition and misinformation promoted on Twitter, highlighting Twitter accounts that drive conversation. Methods. We used supervised machine learning to code all Twitter posts. We first identified codes and themes manually by using a grounded theoretical approach and then applied them to the full data set algorithmically. We identified the top 50 authors month-over-month to determine influential sources of information related to vaccine opposition. Results. The data collection period was June 1 to December 1, 2019, resulting in 356 594 mentions of vaccine opposition. A total of 129 Twitter authors met the qualification of a top author in at least 1 month. Top authors were responsible for 59.5% of vaccine-opposition messages. We identified 10 conversation themes. Themes were similarly distributed across top authors and all other authors mentioning vaccine opposition. Top authors appeared to be highly coordinated in their promotion of misinformation within themes. Conclusions. Public health has struggled to respond to vaccine misinformation. Results indicate that sources of vaccine misinformation are not as heterogeneous or distributed as it may first appear given the volume of messages. There are identifiable upstream sources of misinformation, which may aid in countermessaging and public health surveillance.

Using social media influencers to increase knowledge and positive attitudes toward the flu vaccine.

Seasonal influenza affects millions of people across the United States each year. African Americans and Hispanics have significantly lower vaccination rates, and large-scale campaigns have had difficulty increasing vaccination among these two groups. This study assessed the feasibility of delivering a flu vaccination promotion campaign using influencers, and examined shifts in social norms regarding flu vaccine acceptability after a social media micro influencer campaign. Influencers were asked to choose from vetted messages and create their own original content promoting flu vaccination, which was posted to their social media pages. Content was intentionally unbranded to ensure that it aligned with the look and feel of their pages. Cross-sectional pre- and post-campaign surveys were conducted within regions that received the campaign and control regions to examine potential campaign impact. Digital metrics assessed campaign exposure. Overall, 117 influencers generated 69,495 engagements. Results from the region that received the campaign showed significant increases in positive beliefs about the flu vaccine, and significant decreases in negative community attitudes toward the vaccine. This study suggests that flu campaigns using a ground-up rather than top-down approach can feasibly reach at-risk groups with lower vaccination rates, and shows the potentials of using an influencer-based model to communicate information about flu vaccination on a large scale.

Content Themes and Influential Voices Within Vaccine Opposition on Twitter, 2019.

Objectives. To report on vaccine opposition and misinformation promoted on Twitter, highlighting Twitter accounts that drive conversation.Methods. We used supervised machine learning to code all Twitter posts. We first identified codes and themes manually by using a grounded theoretical approach and then applied them to the full data set algorithmically. We identified the top 50 authors month-over-month to determine influential sources of information related to vaccine opposition.Results. The data collection period was June 1 to December 1, 2019, resulting in 356 594 mentions of vaccine opposition. A total of 129 Twitter authors met the qualification of a top author in at least 1 month. Top authors were responsible for 59.5% of vaccine-opposition messages. We identified 10 conversation themes. Themes were similarly distributed across top authors and all other authors mentioning vaccine opposition. Top authors appeared to be highly coordinated in their promotion of misinformation within themes.Conclusions. Public health has struggled to respond to vaccine misinformation. Results indicate that sources of vaccine misinformation are not as heterogeneous or distributed as it may first appear given the volume of messages. There are identifiable upstream sources of misinformation, which may aid in countermessaging and public health surveillance.

Evaluation of a campaign to reduce consumption of sugar-sweetened beverages in New Jersey.

Obesity is a leading cause of premature death in the U.S., in part due to consumption of sugar sweetened beverages (SSBs). In New Jersey, African Americans, Hispanics, and those of low income have the highest rates of SSB consumption. This study evaluates the impact of NJ Sugarfreed, a campaign designed to reduce sugar-sweetened beverage (SSB) consumption across New Jersey. From 12/1/17-9/30/18, we used a collective impact model to create targeted statewide campaigns that reduce SSB consumption among New Jersey residents, with an emphasis on African American and Hispanic low-income mothers/caregivers who are often gatekeepers to children's SSB consumption. Passaic County, New Jersey received a higher dose intervention. Messages were disseminated through social media, partner organizations, and community partnerships. Campaign impact was examined through evaluation surveys and analysis of beverage sales. Baseline and follow-up surveys (n = 800 baseline; n = 782 follow-up) showed positive trends toward decreased soda consumption and increased knowledge about SSBs. Passaic respondents showed a 5% decrease in those who consume 1+ soda per day, compared to a 1% decrease among New Jersey respondents. Analysis of overall SSB beverage sales showed the most pronounced decreases in Passaic (7% decrease) compared to New Jersey (6%). By drawing upon best practices in message development and the use of various platforms for dissemination, combined with community-based participation, we have provided more evidence to support the use of a collective impact model as a way of reducing unhealthy behaviors that impact health disparities.

Alcohol Consumption and Incident Kidney Disease: Results From the Atherosclerosis Risk in Communities Study.

OBJECTIVE(S): Moderate alcohol consumption has been found to be associated with lower risk of coronary heart disease and myocardial infarction, which share similar risk factors and pathophysiology with chronic kidney disease (CKD). However, there is inconsistent evidence on the association between alcohol consumption and CKD. DESIGN AND METHODS: We conducted a prospective analysis of 12,692 participants aged 45-64 years from the Atherosclerosis Risk in Communities (ARIC) study. We categorized participants into 6 alcohol consumption categories: never drinkers, former drinkers, ≤1 drink per week, 2 to 7 drinks per week, 8 to 14 drinks per week, and ≥15 drinks per week based on food frequency questionnaire responses at visit 1 (1987-1989). Incident CKD was defined as estimated glomerular filtration rate <60 mL/minute/1.73 m2 accompanied by ≥25% estimated glomerular filtration rate decline, a kidney disease-related hospitalization or death or end-stage renal disease. RESULTS: During a median follow-up of 24 years, there were 3,664 cases of incident CKD. Current drinkers were more likely to be men, whites, and to have a higher income level and education level. After adjusting for total energy intake, age, sex, race-center, income, education level, health insurance, smoking, and physical activity, there was no significant association between being a former drinker and risk of incident CKD. Participants who drank ≤1 drink per week, 2 to 7 drinks per week, 8 to 14 drinks per week, and ≥15 drinks per week had, respectively, a 12% (hazard ratio [HR]: 0.88, 95% confidence interval [CI]: 0.79-0.97), 20% (HR: 0.80, 95% CI: 0.72-0.89), 29% (HR: 0.71, 95% CI: 0.62-0.83), and 23% (HR: 0.77, 95% CI: 0.65-0.91) lower risk of CKD compared with never drinkers. CONCLUSION(S): Consuming a low or moderate amount of alcohol may lower the risk of developing CKD. Therefore, moderate consumption of alcohol may not likely be harmful to the kidneys.

Hypoxemia following generalized convulsive seizures: Risk factors and effect of oxygen therapy.

OBJECTIVE: To analyze the factors that determine the occurrence or severity of postictal hypoxemia in the immediate aftermath of a generalized convulsive seizure (GCS). METHODS: We reviewed the video-EEG recordings of 1,006 patients with drug-resistant focal epilepsy included in the REPO2MSE study to identify those with ≥1 GCS and pulse oximetry (SpO2) measurement. Factors determining recovery of SpO2 ≥ 90% were investigated using Cox proportional hazards models. Association between SpO2 nadir and person- or seizure-specific variables was analyzed after correction for individual effects and the varying number of seizures. RESULTS: A total of 107 GCS in 73 patients were analyzed. A transient hypoxemia was observed in 92 GCS (86%). Rate of GCS with SpO2 <70% dropped from 40% to 21% when oxygen was administered early (p = 0.046). Early recovery of SpO2 ≥90% was associated with early administration of oxygen (p = 0.004), absence of postictal generalized EEG suppression (PGES) (p = 0.014), and extratemporal lobe epilepsy (p = 0.001). Lack of early administration of O2 (p = 0.003), occurrence of PGES (p = 0.018), and occurrence of ictal hypoxemia during the focal phase (p = 0.022) were associated with lower SpO2 nadir. CONCLUSION: Postictal hypoxemia was observed in the immediate aftermath of nearly all GCS but administration of oxygen had a strong preventive effect. Severity of postictal hypoxemia was greater in temporal lobe epilepsy and when hypoxemia was already observed before the onset of secondary GCS.

Deep brain stimulation in five patients with severe disorders of consciousness.

OBJECTIVE: The efficacy of deep brain stimulation in disorders of consciousness remains inconclusive. We investigated bilateral 30-Hz low-frequency stimulation designed to overdrive neuronal activity by dual pallido-thalamic targeting, using the Coma Recovery Scale Revised (CRS-R) to assess conscious behavior. METHODS: We conducted a prospective, single center, observational 11-month pilot study comprising four phases: baseline (2 months); surgery and titration (1 month); blind, random, crossover, 1.5-month ON and OFF periods; and unblinded, 5-month stimulation ON. Five adult patients were included: one unresponsive-wakefulness-syndrome male (traumatic brain injury); and four patients in a minimally conscious state, one male (traumatic brain injury) and three females (two hemorrhagic strokes and one traumatic brain injury). Primary outcome measures focused on CRS-R scores. Secondary outcome measures focused notably on baseline brain metabolism and variation in activity (stimulation ON - baseline) using normalized fluorodeoxyglucose positron emission tomography maps. Statistical analysis used random-effect models. RESULTS: The two male patients (one minimally conscious and one unresponsive wakefulness syndrome) showed improved mean CRS-R scores (stimulation ON vs. baseline), in auditory, visual and oromotor/verbal subscores, and visual subscores respectively. The metabolism of the medial cortices (low at baseline in all five patients) increased specifically in the two responders. INTERPRETATION: Our findings show there were robust but limited individual clinical benefits, mainly in visual and auditory processes. Overall modifications seem linked to the modulation of thalamo-cortico-basal and tegmental loops activating default mode network cortices. Specifically, in the two responders there was an increase in medial cortex activity related to internal awareness.

Epilepsy diagnostic and treatment needs identified with a collaborative database involving tertiary centers in France.

OBJECTIVE: To obtain perspective on epilepsy in patients referred to tertiary centers in France, and describe etiology, epilepsy syndromes, and identify factors of drug resistance and comorbidities. METHODS: We performed a cross-sectional analysis of the characteristics of 5,794 pediatric and adult patients with epilepsy included in a collaborative database in France between 2007 and 2013. Comparisons between groups used Student's t-test or Fisher's exact test for binary or categorical variables. Factors associated with drug resistance and intellectual disability were evaluated in multi-adjusted logistic regression models. RESULTS: Mean age at inclusion was 17.9 years; children accounted for 67%. Epilepsy was unclassified in 20% of patients, and etiology was unknown in 65%, including those with idiopathic epilepsies. Etiologies differed significantly in adult- when compared to pediatric-onset epilepsy; however, among focal structural epilepsies, mesial temporal lobe epilepsy with hippocampal sclerosis began as often in the pediatric as in adult age range. Drug resistance concerned 53% of 4,210 patients evaluable for seizure control and was highest in progressive myoclonic epilepsy (89%), metabolic diseases (84%), focal cortical dysplasia (70%), other cortical malformations (69%), and mesial temporal lobe epilepsy with hippocampal sclerosis (67%). Fifty-nine percent of patients with focal structural epilepsy and 69% with epileptic encephalopathies were drug resistant; however, 40-50% of patients with West syndrome and epileptic encephalopathy with continuous spike-and-waves during sleep were seizure-free. Ages at onset in infancy and in young adults shared the highest risk of drug resistance. Epilepsy onset in infancy comprised the highest risk of intellectual disability, whereas specific cognitive impairment affected 36% of children with idiopathic focal epilepsy. SIGNIFICANCE: Our study provides a snapshot on epilepsy in patients referred to tertiary centers and discloses needs for diagnosis and treatment. Large databases help identify patients with rare conditions that could benefit from specific prospective studies.

Anti-NMDA-R encephalitis: Should we consider extreme delta brush as electrical status epilepticus?

Seizures are common clinical manifestations in anti-N-methyl-d-aspartate receptor (anti-NMDA-R) encephalitis, among other neurological and psychiatric symptoms. During the course of the disease, some specific EEG patterns have been described: generalized rhythmic delta activity (GRDA) and extreme delta brush (EDB). In comatose patients, the association of these EEG abnormalities with subtle motor manifestations can suggest ongoing non-convulsive status epilepticus (NCSE). We report the case of a 28-year-old woman admitted for a clinical presentation typical of anti-NMDA-R encephalitis, which was confirmed by CSF analysis. She was rapidly intubated because of severe dysautonomia and disturbed consciousness. Clinical examination revealed subtle paroxysmal and intermittent myoclonic and tonic movements, correlated on video-EEG with GRDA and/or EDB. NCSE was then suspected, but electroclinical manifestations persisted despite many anti-epileptic drugs combinations, or reappeared when barbiturate anesthesia was decreased. In order to confirm or dismiss the diagnosis, intracranial pressure (ICP) and surface video-EEG monitoring were performed simultaneously and revealed no ICP increase, thus being strongly against a diagnosis of seizures. Sedation was progressively weaned, and clinical condition as well as EEG appearance progressively improved. Literature review revealed 11 similar cases, including 2 with focal NCSE. Of the nine other cases, NCSE diagnosis was finally excluded in 5 cases. NCSE diagnosis in association with anti-NMDA-R encephalitis is sometimes very difficult and its occurrence might be overestimated. Video-EEG is highly recommended and more invasive techniques may sometimes be necessary.

Risk factors of postictal generalized EEG suppression in generalized convulsive seizures.

OBJECTIVE: To identify the clinical determinants of occurrence of postictal generalized EEG suppression (PGES) after generalized convulsive seizures (GCS). METHODS: We reviewed the video-EEG recordings of 417 patients included in the REPO2MSE study, a multicenter prospective cohort study of patients with drug-resistant focal epilepsy. According to ictal semiology, we classified GCS into 3 types: tonic-clonic GCS with bilateral and symmetric tonic arm extension (type 1), clonic GCS without tonic arm extension or flexion (type 2), and GCS with unilateral or asymmetric tonic arm extension or flexion (type 3). Association between PGES and person-specific or seizure-specific variables was analyzed after correction for individual effects and the varying number of seizures. RESULTS: A total of 99 GCS in 69 patients were included. Occurrence of PGES was independently associated with GCS type (p < 0.001) and lack of early administration of oxygen (p < 0.001). Odds ratio (OR) for GCS type 1 in comparison with GCS type 2 was 66.0 (95% confidence interval [CI 5.4-801.6]). In GCS type 1, risk of PGES was significantly increased when the seizure occurred during sleep (OR 5.0, 95% CI 1.2-20.9) and when oxygen was not administered early (OR 13.4, 95% CI 3.2-55.9). CONCLUSION: The risk of PGES dramatically varied as a function of GCS semiologic characteristics. Whatever the type of GCS, occurrence of PGES was prevented by early administration of oxygen.