The effect of right atrial catheters on infectious complications of chemotherapy in children.

Rates of infections and catheter complications in children with right atrial catheters (RACs) receiving chemotherapy were compared with those without RACs in a retrospective cohort study. One hundred sixty-five children presenting to Yale-New Haven Hospital with a malignancy diagnosed between January 1, 1981 and December 31, 1985 were followed through June 30, 1986 for the number of treatment-related complications resulting in hospitalization. The time on therapy totaled 80,089 person-days that were divided into 510 periods of observation defined by the presence or absence of a RAC, disease status (remission, partial remission, or relapse), intensity of chemotherapy (using a 0 to 4 scale), and use of radiation therapy. Children with RACs experienced markedly higher rates of sepsis (14-fold higher, P less than .0001) and catheter-site infection or other catheter complications requiring hospitalization (both greater than 30-fold higher, P less than .0001). These effects persisted after controlling for other risk factors, ie, disease status, chemotherapy intensity, and age. Children with RACs also had higher rates of fever and neutropenia and other infections requiring hospitalization that were more strongly influenced by the other risk factors. The association of RACs with sepsis, fever and neutropenia, and days hospitalized for treatment-related complications was assessed using multivariable analysis methods to control for disease status, intensity of chemotherapy, radiation therapy, type of cancer, age, and sex. The presence of a RAC (rate ratio [RR], 6.39; P less than .0001) and the disease status (RR, 2.45; P = .0004) were the only factors that predicted sepsis. Fever and neutropenia rates were most influenced by chemotherapy intensity (RR, 2.31; P = .0001) and age (RR, 0.94; P = .013 per year of age) and less by the presence of a RAC (RR, 1.56; P = .053). Controlling for other risk factors, children with RACs experienced a 6.4-times higher rate of sepsis and spent an average of 15.4 more days per year in the hospital for treatment-related complications.

Cell death in the mammalian visual system during normal development: II. Superior colliculus.

Degenerating cells may be observed with light microscopy in the hamster superior colliculus during early postnatal development. In the superficial gray layer and stratum opticum, 1.8 degenerating cells for each 1,000 live cells could be seen on the first postnatal day. This rate increased to 5.6 degenerating cells per 1,000 live cells by postnatal day 8. The rate of cell degeneration was consistently elevated at the medial, lateral, and caudal margins of the superficial gray layer relative to the center. In the intermediate and deep gray layers, the rate of cell death was consistently higher, starting at three degenerating cells per 1,000 on postnatal day 5, and declining to 4.7 per 1,000 by postnatal day 8. In contrast to the superficial gray layer, the number of degenerating cells in the central versus peripheral segments of the intermediate and deep gray layers was quite similar. Although the rate of observable degeneration is low, the likely rapid clearance of degenerating cell debris indicates a substantial loss of cells from the midbrain tectum in early development. The time course of observable degeneration, the amount, and the distribution of degenerating cells are quite similar in the tectum, and its major innervating structure, the retina.

The risk of seizure recurrence following a first unprovoked seizure: a quantitative review.

Knowledge of the recurrence risk following a first unprovoked seizure and the predictors of that risk are necessary for rational treatment decisions. Published estimates of recurrence risk range from 23% to 71%. In a meta-analysis of 16 reports, three methodologic factors explained much of the reported variation: (1) study inclusion criteria, ie, whether patients were enrolled at the time of their first seizure or if patients with prior seizures were included; (2) retrospective versus prospective ascertainment of patients; (3) the interval between the first seizure and the time at which risk was assessed. The average recurrence risk across the 16 studies was 51%. The risk was 40% and 52% in prospective and retrospective studies that employed first-seizure methods and 67% in non-first seizure studies. At or near 2 years following the first seizure, the recurrence risk was 36% and 47% in prospective and retrospective first-seizure studies. The distribution of prognostic factors was also important. Seizure etiology and the EEG were the strongest predictors of recurrence distinguishing between patient subgroups, with recurrence risks as low as 24% and as high as 65%. Partial seizures were associated with an increased recurrence risk, but not consistently. There is considerable agreement among studies concerning the recurrence risk following a first seizure, and much of the discrepancies among studies can be explained by differences in study methods and distributions of important prognostic factors.

Unprovoked seizures in children with febrile seizures: short-term outcome.

BACKGROUND: Febrile seizures affect 2 to 4% of children, and 2 to 10% develop subsequent unprovoked seizures. Secondary analyses of two large cohorts identified neurodevelopmental abnormalities, complex febrile seizures, and a family history of epilepsy as predictors of unprovoked seizures. We present an analysis of children prospectively followed from their first febrile seizure to reassess these three factors, examine factors of equivocal importance, and assess the importance of some new factors that we identified as predictors of recurrent febrile seizures. METHODS: Children (N = 428) were prospectively identified for a first febrile seizure through pediatric emergency departments of four hospitals. Information was collected from medical records and interviews with parents. Children were followed for 2 years or more. RESULTS: Unprovoked seizures occurred in 26 (6%). Neurodevelopmental abnormalities, complex febrile seizures, and a family history of epilepsy were associated with an increased risk of unprovoked seizures. Recurrent febrile seizures and brief duration of fever before the initial febrile seizure were also risk factors. A family history of febrile seizures, temperature and age at the initial febrile seizure, sex, and race were not associated with unprovoked seizures. CONCLUSIONS: We confirmed the increased risk associated with traditionally accepted predictors of epilepsy following febrile seizures. Also, the risk clearly increased with recurrent febrile seizures. In general, predictors of subsequent unprovoked seizures differ from predictors of recurrent febrile seizures. One notable exception, brief duration of fever before the initial febrile seizure, predicts both types of outcome and may be a marker for an increased susceptibility to seizures.

Relapse following discontinuation of antiepileptic drugs: a meta-analysis.

The estimates in the literature of the risk of seizure relapse after antiepileptic medications are withdrawn range from less than 10% to nearly 70%. There is also little coherence regarding predictors of successful medication withdrawal. We performed a meta-analysis of the published literature to date to determine the risk of relapse at 1 and 2 years after discontinuation of medications and to examine the strength of association between the risk of relapse and three commonly assessed clinical factors: age of onset of epilepsy, presence of an underlying neurologic condition, and an abnormal EEG. We established criteria for inclusion of a study in the analysis, and 25 studies met these criteria. Overall, the risk of relapse at 1 year was 0.25 (95% CI, 0.21 to 0.30) and at 2 years it was 0.29 (95% CI, 0.24 to 0.34). Relative to epilepsy of childhood onset, epilepsy of adolescent onset was associated with a relative risk of relapse of 1.79 (95% CI, 1.46 to 2.19). Compared with childhood-onset epilepsy, adult-onset epilepsy was associated with a relative risk of 1.34 (95% CI, 1.00 to 1.81). Patients with remote symptomatic seizures were more likely to relapse than patients with idiopathic seizures; the relative risk was 1.55 (95% CI, 1.21 to 1.98). An abnormal EEG was associated with a relative risk of 1.45 (95% CI, 1.18 to 1.79). Although these figures help provide an estimate of an individual's likelihood of relapse, they should not be used as the sole basis on which to make the decision on discontinuation of medications.(ABSTRACT TRUNCATED AT 250 WORDS)

Sleep state and the risk of seizure recurrence following a first unprovoked seizure in childhood.

In a prospective study, we have followed 347 children identified at the time of a first unprovoked seizure for a mean of 46 months. To date, 135 (39%) have experienced a seizure recurrence. In this study, we analyzed recurrence risk as a function of whether the child was asleep or awake at the time of the first seizure. The cumulative recurrence risks for children whose first seizure occurred in sleep was 28% at 0.5 years, 39% at 1 year, 53% at 2 years, and 55% at 4 years, compared with recurrence risks of 18%, 23%, 30%, and 35% at the same intervals in children whose first seizure occurred while awake (p < 0.001). The association of a first seizure during sleep with an increased recurrence risk was present primarily in children with idiopathic seizures. It occurred in both those with a normal and an abnormal EEG. On multivariable analysis, sleep state, etiology, and the EEG were statistically significant predictors of recurrence risk. In children who experienced a seizure recurrence, the recurrences occurred in the same sleep state in 73% of the cases (p < 0.0001). This was also true of subsequent recurrences. We conclude that the occurrence of a first seizure in sleep is associated with an increased risk of recurrence. Subsequent seizures, if they do occur, usually occur in the same sleep state as the initial seizure.

Childhood-onset epilepsy with and without preceding febrile seizures.

OBJECTIVE: To identify characteristics in children with epilepsy that differ between those who did versus did not have a history of preceding febrile seizures. BACKGROUND: Febrile seizures precede epilepsy in 10 to 15% of children. Little is known about the specific types of epilepsy associated with febrile seizures. METHODS: In a community-based, prospectively identified cohort of children, the association between prior febrile seizures and characteristics of the children's epilepsy (seizure type, epilepsy syndrome, age at onset, underlying etiology, family history) were examined for 524 of the children who were aged > or =1 year at onset of epilepsy. RESULTS: Seventy-three (13.9%) had febrile seizures. Children with febrile seizures were more likely to have a first-degree or a second-higher-degree relative with febrile seizures and less likely to have childhood absence epilepsy and absence seizures compared with children without febrile seizures. This was especially true for simple febrile seizures. There was no specific association with localization-related forms of epilepsy. Complex, but not simple, febrile seizures were associated with younger age at onset of epilepsy. There was no evidence that focal or prolonged febrile seizures were associated with localization-related epilepsy or temporal lobe epilepsy per se. Of the three children whose initial MRIs demonstrated hippocampal atrophy, none had a history of febrile seizures. CONCLUSIONS: At the time of diagnosis, febrile seizures are not specifically related to temporal lobe epilepsy or localization-related epilepsy in general. A genetic component for febrile seizures is suggested by its positive associations with family history, especially for simple febrile seizures. Complex febrile seizures represent an underlying age-dependent susceptibility.

Early development of intractable epilepsy in children: a prospective study.

BACKGROUND: Little is known about early prediction of intractable epilepsy (IE) in children. Such information could help guide the early use of new therapies in selected patients. METHODS: Children with newly diagnosed epilepsy (n = 613) were prospectively identified from child neurology practices in Connecticut (1993--1997) and followed-up for the occurrence of IE (failure of > or = 2 drugs, > or = 1 seizure/month, over 18 months) [corrected]. Etiology and epilepsy syndromes were classified per International League Against Epilepsy guidelines. RESULTS: The median follow-up is 4.8 years, and 599 (97.7%) have been followed for more than 18 months. Sixty children (10.0%) have met the criteria for IE, including 34.6% with cryptogenic/symptomatic generalized, 2.7% with idiopathic, 10.7% with other localization-related, and 8.2% with unclassified epilepsy (p < 0.0001). After multivariable adjustment for epilepsy syndrome, initial seizure frequency (p < 0.0001), focal EEG slowing (p = 0.02), and acute symptomatic or neonatal status epilepticus (p = 0.001) were associated with an increased risk of IE, and age at onset between 5 and 9 years was associated with a lowered risk (p = 0.03). The absolute number of seizures and unprovoked or febrile status epilepticus were not associated substantially with IE. CONCLUSIONS: Approximately 10% of children meet criteria for IE early in the course of their epilepsy. Cryptogenic/symptomatic generalized syndromes carry the highest risk and idiopathic syndromes the lowest. Half of IE occurs in children with nonidiopathic localization-related syndromes. Initial seizure frequency is highly predictive of IE. By contrast, absolute number of seizures and unprovoked or febrile status epilepticus are not.

Driving in adults with refractory localization-related epilepsy. Multi-Center Study of Epilepsy Surgery.

OBJECTIVE: To examine the frequency of driving an automobile and characteristics associated with driving in individuals with refractory localization-related epilepsy. BACKGROUND: Driving is generally restricted and monitored in people with epilepsy. Little is known about the frequency of driving and subsequent accidents specifically in individuals with uncontrolled epilepsy. METHODS: In an ongoing, prospective, multicenter study of resective epilepsy surgery, individuals were interviewed when they presented for surgical evaluation. Analyses were conducted using chi-square, t-tests, and multiple logistic regression. RESULTS: Of 367 eligible participants, 115 (31.3%) had driven in the last year, most on at least a weekly basis. In a multivariable analysis, factors associated with an increased likelihood of driving were having a current license (OR = 10.71, p < 0.001) and ever having had a license (OR = 3.86, p = 0.003). Younger individuals were also more likely to drive. Lower levels of driving were found in women (OR = 0.31, p < 0.001), individuals who were self-described as disabled (OR = 0.20, p < 0.001), and those who were employed full-time (OR = 0.43, p = 0.03) or part-time (OR = 0.15, p = 0.005). At some point in the past, 144 individuals experienced one or more seizures while driving, and 98 experienced at least one accident because of a seizure. Of those who had accidents, 94% reported property damage, 32% had an injury, and 20% caused injury to others. CONCLUSION: Despite restrictions, almost one third of individuals with refractory epilepsy drive. Understanding why they do may help identify means of modifying this behavior or identifying services that, if provided, would help people with uncontrolled epilepsy forego driving.

Protective efficacy of Haemophilus influenzae type b polysaccharide vaccine.

There has been uncertainty and controversy about the protective efficacy of Haemophilus influenzae type b polysaccharide vaccine almost since it first was licensed in the United States. This article will briefly review the available epidemiologic data about the protective efficacy of this vaccine in children with no recognized underlying illnesses. H influenzae type b polysaccharide vaccine was licensed in the United States in April 1985, based on the results of a randomized clinical trial that was conducted in Finland. That study indicated that the vaccine's protective efficacy was 90% against invasive disease caused by H influenzae type b in children 18 to 71 months of age. Authorities recommended that all children receive the vaccine at 2 years of age and that it be administered to children up to the age of 60 months. The Immunization Practices Advisory Committee also recommended that children at increased risk (such as those who attend group day care) receive the vaccine at 18 months and again at 24 months of age because of its inconsistent immunogenicity when administered to 18-month-old children. Soon after its licensure, however, reports of vaccine failures began to appear. In some instances the vaccine failure could be attributed to an identifiable immune deficiency. However, Granoff et al reported 54 apparently normal children who had received the H influenzae type b polysaccharide vaccine but subsequently developed invasive disease caused by H influenzae type b. The majority of these children had normal serum concentrations of total immunoglobulins, IgG2, hemolytic complement, and antibody to tetanus toxoid (a T-cell-dependent antigen).(ABSTRACT TRUNCATED AT 250 WORDS)

Does breast-feeding protect against infections in infants less than 3 months of age?

To determine whether breast-feeding protects infants from infections, a case-control study was conducted. The cases were previously healthy children who were admitted to Yale-New Haven Hospital for an infectious illness at or before 90 days of age. The controls were chosen from the log of births and matched to the cases for five important demographic variables. In addition, logistic regression models were used to adjust the results for other potential confounders. To minimize the potential surveillance bias that might occur if formula-fed and breast-fed infants with the same degree of illness have a different probability of being hospitalized, the case-control pairs were stratified by the severity of the medical condition of the case at the time of hospitalization. For the 281 case-control pairs, the matched odds ratio was .50 (95% confidence interval .32, .77; P less than .005), which indicates that breast-feeding is protective against infections. However, this apparent protective effect was diminished substantially when the data were stratified according to the severity of illness: the matched odds ratio for the 164 infants with serious illnesses was .79 (.47, 1.32; P less than .50), and for the 117 infants with mild illnesses it was .17 (.03, .44; P less than .001). These stratified results suggest that breast-feeding protects infants from hospitalization rather than from infections. Failure to consider the problem of surveillance bias may lead to erroneous conclusions about the protective effect of breast-feeding.

Are children born to young mothers at increased risk of maltreatment?

Previous case-control or cross-sectional studies have provided conflicting results about whether children of teenage mothers are at increased risk of maltreatment compared with children of older mothers. This study is the first to examine this question using a longitudinal, cohort design and the first to address important methodologic issues such as detection bias. Subjects were 219 consecutive index children born to inner-city women who were 18 years or younger and 219 sociodemographically similar comparison children born to women 19 years or older. Data were collected by reviewing the medical records of each child through the fifth birthday. Three outcomes were examined: maltreatment, poor growth, and a change in the child's primary caretaker. Maltreatment was ascertained by having two experts, one of whom was blind to the group status, review each injury documented in the records. Predefined criteria were used to distinguish unintentional injuries from maltreatment (abuse, neglect, or sexual abuse). Maltreatment occurred more frequently in the children of young mothers (12.8%) than in the comparison group (6.4%) (risk ratio [RR] = 2.00; 95% confidence interval [CI] = 1.17, 3.64). Poor growth, defined by growth criteria, occurred in 6.9% of the index group and in 4.1% of comparison children (RR = 1.67; 95% CI = 0.75, 3.73). A change in the child's primary caretaker, either because of placement in foster care or because the mother left the home, occurred in 12.8% of the index group and in 3.2% in comparison children (RR = 4.00; 95% CI = 1.80, 8.87).(ABSTRACT TRUNCATED AT 250 WORDS)

Use of health services by children who were identified during the postpartum period as being at high risk of child abuse or neglect.

OBJECTIVE: To examine the rates of hospitalizations of children identified as beingat high risk of maltreatment compared with a sociodemographically similar comparison group. DESIGN: retrospective study comparing a high-risk cohort with a sociodemographically matched comparison group at Yale-New Haven Hospital (New Haven, CT). PATIENTS: One huntred fourteen children who were identified from January 1979 through December 1981 by clinicians on the postpartum ward as being at high risk of abuse or neglect and 114 sociodemographically similar comparison children who were matched according to date of birth, race, gender, and method of payment for the hospitalization. MAIN OUTCOME MEASURER: During the first 4 years of life, the number of hospitalizations, reasons for admissions, and appropriateness of days in the hospital using the Pediatric Appropriateness Evaluation Protocol. RESULTS: Significantly more high-risk children wer hospitalized (40% vs 22%; risk ratio 1.84; 95% confidence interval, 1.23-2.74). High-risk children were hospitalized for 649 (mean, 9.0) days versus 124 (mean, 3.8) days in comparison children. For admissions for medical problems, 28% of hospital days in the high-risk group were considered inappropriate by the Pediatric Appropriateness Evaluation Protocol versus 8% in the comparison group. CONCLUSIONS: There are substantial differences in the rates of hospitalizations, lengths of stay, and appropriateness of days in children identified as being at hish risk of maltreatment compared with a sociodemographically similar, non-high-risk group. Preventive programs that are aimed at reducing rates of child maltreatment in high-risk young children also should examine the program's effects on the use of hospital care.

The risk of seizure recurrence after a first unprovoked afebrile seizure in childhood: an extended follow-up.

OBJECTIVE: To assess the long-term recurrence risks after a first unprovoked seizure in childhood. METHODS: In a prospective study, 407 children who presented with a first unprovoked seizure were then followed for a mean of 6.3 years from the time of first seizure. RESULTS: One hundred seventy-one children (42%) experienced subsequent seizures. The cumulative risk of seizure recurrence was 29%, 37%, 42%, and 44% at 1, 2, 5, and 8 years, respectively. The median time to recurrence was 5.7 months, with 53% of recurrences occurring within 6 months, 69% within 1 year, and 88% within 2 years. Only 5 recurrences (3%) occurred after 5 years. On multivariable analysis, risk factors for seizure recurrence included a remote symptomatic etiology, an abnormal electroencephalogram (EEG), a seizure occurring while asleep, a history of prior febrile seizures, and Todd's paresis. In cryptogenic cases, the risk factors were an abnormal EEG and an initial seizure during sleep. In remote symptomatic cases, risk factors were a history of prior febrile seizures and age of onset younger than 3 years. Risk factors for late recurrences (after 2 years) were etiology, an abnormal EEG, and prior febrile seizures in the overall group and an abnormal EEG in the cryptogenic group. These are similar to the risk factors for early recurrence. CONCLUSIONS: The majority of children with a first unprovoked seizure will not have recurrences. Children with cryptogenic first seizures and a normal EEG whose initial seizure occurs while awake have a particularly favorable prognosis, with a 5-year recurrence risk of only 21%. Late recurrences do occur but are uncommon.

Risk of seizure recurrence following a first unprovoked seizure in childhood: a prospective study.

In a prospective study, 283 children who presented with a first unprovoked seizure were followed for a mean of 30 months from the time of first seizure. Subsequent seizures were experienced by 101 children (36%). The cumulative risk of seizure recurrence for the entire study group was 26% at 12 months, 36% at 24 months, 40% at 36 months, and 42% at 48 months. The cumulative risk of recurrence in the 47 children with a remote symptomatic first seizure was 37%, 53%, and 60% at 12, 24, and 36 months, respectively, compared with a cumulative risk of 24%, 33%, and 36% at 12, 24, and 36 months, respectively, in the 236 children who had had an idiopathic first seizure (P less than .01). In children with an idiopathic first seizure, the electroencephalogram was the most important predictor of recurrence. The cumulative risk of recurrence in the 81 children with abnormal electroencephalograms was 41%, 54%, and 56% at 12, 24 and 36 months, respectively, but only 15%, 23%, and 26% at 12, 24, and 36 months, respectively, in the 138 children with normal electroencephalograms (P less than .001). A history of epilepsy in a first-degree relative was a significant risk factor only in idiopathic cases with abnormal electroencephalograms. In children with a remote symptomatic first seizure, either a history of prior febrile seizures or the occurrence of a partial seizure were significant predictors of recurrence. Age at first seizure and duration of seizure did not affect recurrence risk in either the idiopathic or remote symptomatic group. A total of 84% of the children were not treated with antiepileptic drugs or were treated for less than 2 weeks. Only 9% were treated for longer than 3 months. Treatment did not affect the risk of recurrence. The results suggest that, even without treatment, the majority of children with a first unprovoked seizure will not experiment a recurrence. Children with an idiopathic first seizure and a normal electroencephalogram have a particularly favorable prognosis.

Screening for lead poisoning in an urban pediatric clinic using samples obtained by fingerstick.

OBJECTIVE: To assess the false positive rate of blood lead (BPb) determinations on samples obtained by fingerstick from children screened in an urban clinic. METHOD: From a single fingerstick (N = 1573), blood was collected in a capillary tube for determining lead concentration (CPb) by graphite furnace and an additional sample was absorbed onto a filter paper for determining lead concentration (FPb) by atomic absorption spectrophotometry with Delves cup. Zinc protoporphyrin (ZPP) was measured immediately and a confirmatory venous lead (VPb) specimen was obtained at the same visit if the ZPP was > or = 35 micrograms/dL (0.6 mumol/L); children with either a CPb or FPb > or = 15 micrograms/dL (0.7 mumol/L) were later recalled for determining VPb. RESULTS: For the 172 children who had a VPb on the same day as the screening tests, the false positive rates (95% confidence intervals) at a lead threshold of 15 micrograms/dL (0.7 mumol/L) were: CPb, 13.5% (6.7-20.3); FPb, 19.1% (11.8-26.4). Analyses using all 679 screens with a paired venous specimen (mean delay between screen and venous testing = 30 days) yielded much higher false positive rates (CPb, 31.3%; FPb, 46.0%). CONCLUSIONS: Screening for lead poisoning is feasible within an urban pediatric clinic by direct measurement of lead concentration in blood samples obtained by fingerstick. The false positive rate that can be obtained is acceptable given the precision of measuring BPb concentration. Practitioners using a staged screening protocol may incorrectly attribute a higher false positive rate to the screening tests, when much of the error may be due to the temporal variability of BPb resulting from both biologic variability in BPb concentration and intermittent exposures.

Treatment of newly diagnosed pediatric epilepsy: a community-based study.

OBJECTIVE: To determine the patterns and frequency of treatment and use of specific drugs for newly diagnosed pediatric epilepsy. DESIGN AND SETTING: Prospective, community-based study. Children were recruited from physicians in Connecticut from 1993 to 1997. PATIENTS: Children aged 1 month through 15 years at the time of their first seizure, who had 2 or more unprovoked seizures, and who were newly diangosed during the recruitment period were eligible. MAIN OUTCOME MEASURE: Initiation of treatment at diagnosis and within 1 year after diagnosis of epilepsy. RESULTS: Of 613 children, 482 (78.6%) were treated at the time of initial diagnosis. By 6 months another 10.3% were treated, and by 12 months 90% of the cohort had been treated. The most commonly prescribed antiepileptic drug (AED) was carbamazepine (38.8%) followed by sodium valproate (18.4%). Only 1 child received an investigational drug and none received any of the most recently approved drugs as a first AED. Children with idiopathic and secondarily generalized forms of epilepsy were most likely to be treated (90%-100%), whereas children with idiopathic localization-related epilepsy were least likely to be treated (50.8%). Approximately 80% of those with other forms of epilepsy were treated at the time of diagnosis. Use of specific medications reflected current guidelines and recommendations for treatment of specific seizure types and syndromes. CONCLUSIONS: In Connecticut, approximately 20% of children with epilepsy are not treated at the time of initial diagnosis, and around 10% continue to be untreated after 1 year. This most likely reflects the increased understanding of the nature of pediatric epilepsy and concerns regarding the adverse effects of AEDs. The most commonly used first drugs are carbamazepine and valproate. Follow-up of this cohort may help provide information to guide the use of recently approved AEDs.

Predictors of recurrent febrile seizures. A prospective cohort study.

OBJECTIVES: To define the risk and identify predictors of single and multiple recurrent febrile seizures. METHODS: Children (n = 428) with first febrile seizures were prospectively identified and followed for 2 or more years. Parents were interviewed soon after their children's first febrile seizure and were called every 3 months to ascertain recurrent febrile seizures. Medical records of first and recurrent seizures were reviewed for additional information. RESULTS: A total of 136 children (31.8%) experienced recurrent seizures: 73 (17.1%) had only 1 recurrence, 38 (8.9%) had 2 recurrences, and 25 (5.8%) had 3 or more recurrences. Young age at onset, a history of febrile seizures in a first-degree relative, low degree of fever while in the emergency department, and a brief duration between the onset of fever and the initial seizure were strong independent predictors of recurrent febrile seizures. With these 4 factors combined, it is possible to define groups of children having very high and very low probabilities of having any recurrences (> 70% vs < 20%), having 2 or more recurrences (> 60% vs < 10%), and having 3 or more recurrence (12% vs about 0%). In children who had at least 1 recurrence, age at the time of the first recurrence and a family history of epilepsy were predictors of subsequent recurrences. CONCLUSIONS: In children who have had a first febrile seizure, recurrences are common. The risk for 1 or more recurrences can be meaningfully predicted at the time of the initial febrile seizure with a combination of the 4 factors identified in this study.

A neuroethological approach to hamster vision.

The contributions of the midbrain optic tectum to visuomotor behaviors likely to be important to hamsters in the wild were studied, including aperture detection, insect catching, and barrier avoidance. Following tectal undercuts, hamsters ceased to make direct approaches to apertures in the posterior 180 degrees of the visual field; this appeared to be mediated by a loss of exploratory or scanning head movements. Reorientation to and pursuit of crickets jumping out of grasp into the visual periphery was impaired, though initial approach to them was not. Barrier avoidance was unaffected by tectal undercuts. This pattern is similar to the contribution of the frog and toad optic tectum to analogous visuomotor tasks. The contribution of the tectum to searching and scanning in the hamster is an extension of the basic orienting capabilities dependent on optic tectum in anurans.