Demographic and geographic variations in the access time of pediatric patients presenting with staring spells.

OBJECTIVE: To assess the demographic and geographic variations in access time - defined as years between the date of symptom onset and initial date of neurological care - in pediatric patients presenting with staring spells. MATERIALS AND METHODS: We conducted a secondary analysis of a retrospective chart review study from 2011 to 2021. A total of 1,353 staring spell patients, aged 0 to 17.9 years, were analyzed for age, sex, race/ethnicity, insurance, county, average county annual per capita personal income, and access time. RESULTS: Patients aged 0-2.9 years had the shortest median access time of 0.3 years, compared to 1.2 years in patients aged 3-12.9 years and 1.0 year in patients aged 13-17.9 years. Statistically significant differences were seen based on race/ethnicity and insurance with White patients having shorter access time of 0.5 years compared to Black patients with 1.0 year and self-pay patients having the shortest access time of 0.4 years compared to patients with private insurance (0.7 years). Warren County had the largest annual per capita personal income of $65,855 and access time of 0.5 years compared to Preble county with the least annual per capita personal income of $45,016 and access time of 1.1 years. CONCLUSION: Demographic parameters of age, race/ethnicity, insurance, and annual county per capita personal income appeared to be associated with access time to initial neurological care in patients with staring spells. These associations need to be investigated further to ensure timely access to neurological care and to ensure equity in health care.

Staring spells in children with autism spectrum disorder: A clinical dilemma.

LAY ABSTRACT: It is a common occurrence for children with autism spectrum disorder to be diagnosed with staring spells. Staring spells are defined as periods of time when children "space out" and are subcategorized as either "absence seizures" (brain activity resembling a seizure but with no physical seizure symptoms) or "non-epileptic spells" (inattentiveness or daydreaming). Due to the subtle characteristics of staring spells, they are usually diagnosed via long-term video electroencephalogram. The child is monitored for 3-5 days with an electroencephalogram which records brain waves. An electroencephalogram may be difficult to perform in children with autism spectrum disorder due to behavior, cognitive, or sensory concerns. Therefore, we wanted to investigate other clinical characteristics that may help us differentiate between epileptic seizures versus non-epileptic spells in children with autism spectrum disorder presenting with staring spells. We reviewed 140 charts retrospectively from the years of 2010-2021. We abstracted demographic and clinical information from the electronic medical record system and reviewed electroencephalogram videos to group the 140 children into epileptic seizure diagnosis group versus non-epileptic spell group. Of the 140 children in this study, 22 were diagnosed with epileptic seizures and the remaining were diagnosed with non-epileptic spells. We found that the two groups differed in certain clinical characteristics such as how long the staring spells lasted, how many staring spells the child had in 1 week, and whether they responded to verbal commands. We believe that clinical features may be helpful in differentiating epileptic seizures from non-epileptic spells in children with autism spectrum disorder.

Peripheral Nerve Blocks: A Tool for Inpatient Pediatric Status Migrainosus.

BACKGROUND: To assess the efficacy and safety of peripheral nerve blocks in the inpatient settings for pediatric patients presenting with status migrainosus. METHODS: An analysis of a retrospective cohort of patients aged 13 to 18 years, admitted for status migrainosus from 2017 to 2022, was performed. Among the 1805 patients who presented with status migrainosus, 265 required hospital admission. A total of 177 patients failed the first- and second-line intravenous therapy and were treated with either peripheral nerve block (PNB) or dihydroergotamine (DHE) intravenous infusions. The primary outcome of the study was pain score level reduction by 50%, and the secondary outcome was duration of hospital stay. Visual analog scale score was used for pain assessment. RESULTS: Among the 177 patients, 100 patients were treated with DHE and 77 were treated with PNB. Target pain control was achieved in 59 of 100 patients receiving DHE and 38 of 77 patients receiving PNB. The average hospital stay of patients who responded to PNB was significantly lower compared with that of patients receiving DHE (3.6 days vs 4.9 days). Among the 41 patients who were refractory to DHE, 30 patients received PNB, of which 12 responded to nerve blocks. The most common side effects for PNBs were pain at injection site in 39% of patients and nausea/vomiting for DHE in 50% of patients. CONCLUSIONS: PNB can be safely administered in the hospital setting to pediatric patients with status migrainosus. PNB treatment helped achieve target pain control with minimal side effects and reduced the hospital stay duration.

Staring Spells: An Age-based Approach Toward Differential Diagnosis.

Evaluations to rule out epileptic vs nonepileptic staring spells may entail unnecessary evaluations that can be costly and time consuming. Our study aims to identify common etiologies for staring spells across 3 different pediatric age groups and to propose an age-based clinical guidance to help determine which patients warrant further workup. Methods: This was a single-center retrospective chart analysis of 1496 patients aged 0.0-17.9 years presenting with confirmed staring spell diagnosis from January 2011 to January 2021. The patients were divided into 3 groups based on their age: 0.0-2.9, 3.0-12.9, and 13.0-17.9 years. Patient information collected included demographics, clinical presentation, comorbidities, and final diagnosis. Multilevel likelihood ratios and a receiver operating characteristic curve were determined using 8 of the 11 clinical variables. A total of 1142 patients who met the inclusion criteria were included for the final analysis. The most common final diagnosis was attention-deficit hyperactivity disorder (ADHD) (35%), followed by normal behavior (33%). Generalized and focal epilepsy were diagnosed in 8% and 4% of the patients, respectively. In the 0.0-2.9-year age group, normal behavior was the final diagnosis in 72% patients. In the 3.0-12.9-year and 13.0-17.9-year age groups, ADHD was the most frequent final diagnosis in 46% and 60%, respectively. Overall, ADHD and normal behaviors remain the most common final diagnoses. Multilevel likelihood ratios can be used to develop an age-based guidance to differentiate between epileptic and nonepileptic staring spell diagnoses.

Rate and Predictors of Intractable Status Migrainosus among Patients Aged 13-18 Years.

Purpose: To assess associations for intractable status migrainosus in the pediatric inpatient setting. Methods: A retrospective cohort study of 1,805 patients presenting to the pediatric hospital in Dayton, Ohio with status migrainosus from 2017 to 2022, was performed. Among 1,805 patients, 159 received 3 lines of sequentially more aggressive abortive migraine treatment and were included in this analysis. Responders and non-responders were categorized based on a visual analogue scale (VAS) of pain scores from time of admission to discharge with responders having a reduction of 50% or greater in VAS. Patient demographic information, migraine history, headache type, medication history, self-reported pain, anxiety level and co-morbidities were assessed. Results: Out of 159 patients, 125 (78.6%) achieved the target pain control with decrease in VAS pain score by ≥ 50% from the baseline. The remaining 34/159 (21.4%) patients remained refractory to treatment. Non-responder patients had a longer hospital stay (6.1 days) and greater readmission rate within 7 days (17.6%) compared to responders (4.7 days and .8% respectively). Among the non-responder patients, 14/34 (41.2%) had attention-deficit/hyperactivity disorder (ADHD) compared to the responder group in which 17/125 (13.6%) had ADHD. Among patients who had comorbidity of anxiety, non-responders had greater severe generalized anxiety disorder (GAD-7 ≥15) (6/14, 42.9%) than responders (2/39, 5.1%). Conclusion: ADHD and severe GAD are associated with poorer response to treatment in pediatric patients with refractory migraine admitted for inpatient therapy. This study highlights the prolonged hospital stay and modest clinical outcomes seen with intractable migraine in 13-18-year-old pediatric patients.

Post COVID-19 Lymphocytic Hypophysitis: A Rare Presentation.

Introduction: Lymphocytic hypophysitis (LH) is a rare autoimmune disorder involving the destruction of the anterior pituitary due to lymphocytic infiltration. The disease shows a female predominance, commonly affecting women during late pregnancy into the postpartum period. The etiology of LH has not been well established and is presumed to be autoimmune based on the histopathological findings of lymphocytic infiltration and postpartum cases. Lymphocytic hypophysitis has yet to be studied in the context of a patient status post-recovery from COVID-19. Since the initial outbreak, additional information regarding the symptoms and outcomes has emerged on the virus's effects on the nervous system. Case: We present a novel case of post-COVID lymphocytic hypophysitis in a pediatric patient at Dayton Children's Hospital. An 18-year-old previously healthy girl presented to the emergency department (ED) with acute onset headache and dizziness for 5 days. She had a history of symptomatic COVID-19 three weeks prior to the onset of current symptoms. Contrast enhanced magnetic resonance imaging (MRI) of the brain revealed diffuse thickening and enlargement of the infundibulum with homogenous contrast enhancement of the hypophyseal axis. Based on the suspicion for lymphocytic hypophysitis, she was started on Methylprednisolone 250 mg IV Q6hrs on day 1-3. Symptomatic clinical improvement was seen on day 3 with a significant decrease in the intensity of the headache. Conclusion: The case illustrates the varied presentation and neurological sequalae associated with the COVID-19 virus. The case described here is the first ever reported post-COVID manifestation of lymphocytic hypophysitis.

Is Botox Right for Me: When to Assess the Efficacy of the Botox Injection for Chronic Migraine in Pediatric Population.

Botulinum toxin type A (BoNT-A) has shown to be a safe and effective treatment for children with chronic migraines. Our study was to assess the efficacy of the Onabotulinum toxin type A at different intervals after initiation of therapy. We conducted a retrospective and prospective analysis of 34 patients at a children's hospital where children received four rounds of the BoNT-A therapy for the treatment of chronic migraine. Among the 34 patients, 25 patients (age range: 13-21 years), who responded to the BoNT-A therapy, were included in the analysis. Patients received standard 31 injection, 155 unit's protocol. Patients were assessed every 3 months after their initial injection. Reasons for discontinuation of therapy were analyzed. After the first two BoNT-A sessions, significant improvement was observed with a decrease in headache frequency and intensity (p < 0.001). There was further reduction in headache frequency and intensity with the fourth round of BoNT-A therapy, with comparative analysis between the second and fourth round showing a p-value of <0.001. In terms of reduction of emergency room visits and hospitalization, a significant improvement was seen after the third round of BoNT-A therapy (p < 0.01). A significant decrease in the number of abortive and preventive medications was seen after the second round of BoNT-A therapy (p < 0.001). The efficacy of BoNT-A treatment in decreasing headache frequency, intensity, and the number of abortive and preventive medications can be assessed effectively after two treatment sessions. This trend continued to be observed with additional third and fourth sessions.

Generalized Anxiety Disorder: A Predictor for Poor Responsiveness to Botulinum Toxin Type A Therapy for Pediatric Migraine.

BACKGROUND: To assess the efficacy, safety, and predictors for poor responsiveness of botulinum toxin type A (BoNT-A) for chronic migraine in the adolescent and young adult population. METHODS: A retrospective analysis of 56 patients who received BoNT-A for chronic migraine with an age range from 13 to 21 years was performed. Of 56 patients, 34 were enrolled in the study based on the inclusion criterion. Patients who received three dosages of BoNT-A were assessed at nine months from the first injection. Variables including age, body mass index, headache intensity, frequency, character, and side effects were assessed. The patients were divided into two groups based on response to BoNT-A therapy, responders and nonresponders. RESULTS: Overall among the 34 patients enrolled in the study, the average headache frequency decreased from 18.6 of 28 to 9.9 of 28 days, P value, <0.001 from baseline. There was significant decrease in the average headache intensity, 8.1 to 4.3. Of 34 patients, 25 (73%) patients responded to treatment with decrease in headache frequency by ≥ 50% from the baseline. Among the nonresponder patients, a significant number of patients (six of nine, 67%) had generalized anxiety disorder with Generalized Anxiety Disorder-7 score greater than 15 versus the responder group (six of 25, 24%, P value 0.040). CONCLUSIONS: BoNT-A remains a safe and effective therapy for adolescent and young adult patients with chronic migraines at nine months of follow-up. Generalized anxiety disorder with Generalized Anxiety Disorder-7 score greater than 15 can be a major predictor of poor response to this therapy.

Pediatric auto-immune encephalitis.

Pediatric Auto-Immune Encephalitis (PAE) is a neuro-inflammatory disorder with a varied presentation. The discovery of the Anti NMDA receptor and other antibodies as the causative agents of PAE, has led to an increased need for guidelines for diagnosis and management of these disorders. PAE remains a challenging group of disorders due to their varying presentations and etiology with a prolonged clinical course. The wide spectrum of clinical symptoms involves altered mental status, movement disorders, acute behavioral changes, psychosis, delirium, seizures, and insomnia. This group of disorders was recently recognized in the children. This review provides clinicians with information on the most common PAE disorders, the spectrum of their clinical presentation, diagnostic tests and treatment protocols based on the current literature.

Selective Head versus Whole Body Cooling Treatment of Hypoxic-Ischemic Encephalopathy: Comparison of Electroencephalogram and Magnetic Resonance Imaging Findings.

OBJECTIVE: This study aimed to compare the utility of electroencephalogram (EEG) and brain magnetic resonance imaging (MRI) to detect brain dysfunction and injury across a cohort of newborn infants treated with selective head cooling (SHC) or whole body cooling (WBC). STUDY DESIGN: Therapeutic hypothermia (TH) is a standard neuroprotection tool for hypoxic-ischemic encephalopathy (HIE) in neonates. Sixty-six newborns, SHC (n = 22) and WBC (n = 44), were studied utilizing standardized scoring systems for interpretation of EEG and MRI based on the severity of the findings. RESULTS: SHC- and WBC-treated groups did not differ significantly amongst most of the baseline parameters. EEGs obtained postcooling were abnormal in 58 of 61 (95%) infants. The severity of the EEG background changes (depressed and undifferentiated background) was more prevalent in the SHC (8/21 [38%]) than in the WBC group (5/40 [13%]). Brain MRIs showed HIE changes in 26 of 62 (42%) newborns treated with TH. MRI abnormalities of basal ganglia, thalamic, and parenchymal lesions were more common in the SHC (5/19) versus the WBC group (3/43); p = 0.04. CONCLUSION: EEG abnormalities and MRI findings of HIE were more prevalent in the SHC than in the WBC group. WBC may offer better or at least similar neuroprotection to infants with HIE.

Mycoplasma pneumoniaeassociated transverse myelitis presenting as asymmetric flaccid paralysis.

Acute transverse myelitis is a rare spinal cord inflammatory disorder that manifests as sudden onset of motor, sensory, and autonomic dysfunctions. Here, we report a case of acute transverse myelitis in a 13- year-old boy secondary to Mycoplasma pneumoniae infection. He presented with left facial palsy and contralateral upper extremity weakness without sensory or autonomic changes. The patient was diagnosed with transverse myelitis based on his magnetic resonance imaging findings, although his presentation was mainly motor dysfunction, which is more consistent with acute flaccid paralysis.

Beriberi disease in an 11-year-old girl with total colectomy.

Beriberi or vitamin B1 deficiency is a rare disease in the developed world and more common in developing countries due to poverty and malnutrition. It usually presents with neurological manifestations (dry beriberi) or cardiovascular signs (wet beriberi). We report a case of dry beriberi in an 11-year-old girl with total colectomy who presented to our hospital with ataxic gait and muscle weakness. Her symptoms started 1 week after she underwent cholecystectomy for her chronic abdominal pain. Nerve conduction study showed sensory demyelinating neuropathy and she had low levels of serum vitamin B1. Her condition improved significantly after taking vitamin B1 supplementation. To the best of our knowledge, this is the first case report of thiamine deficiency in a child with a total colectomy.

Comparative sensitivity of quantitative EEG (QEEG) spectrograms for detecting seizure subtypes.

PURPOSE: To assess the sensitivity of Persyst version 12 QEEG spectrograms to detect focal, focal with secondarily generalized, and generalized onset seizures. METHODS: A cohort of 562 seizures from 58 patients was analyzed. Successive recordings with 2 or more seizures during continuous EEG monitoring for clinical indications in the ICU or EMU between July 2016 and January 2017 were included. Patient ages ranged from 5 to 64 years (mean = 36 years). There were 125 focal seizures, 187 secondarily generalized and 250 generalized seizures from 58 patients analyzed. Seizures were identified and classified independently by two epileptologists. A correlate to the seizure pattern in the raw EEG was sought in the QEEG spectrograms in 4-6 h EEG epochs surrounding the identified seizures. A given spectrogram was interpreted as indicating a seizure, if at the time of a seizure it showed a visually significant departure from the pre-event baseline. Sensitivities for seizure detection using each spectrogram were determined for each seizure subtype. RESULTS: Overall sensitivities of the QEEG spectrograms for detecting seizures ranged from 43% to 72%, with highest sensitivity (402/562,72%) by the seizure detection trend. The asymmetry spectrogram had the highest sensitivity for detecting focal seizures (117/125,94%). The FFT spectrogram was most sensitive for detecting secondarily generalized seizures (158/187, 84%). The seizure detection trend was the most sensitive for generalized onset seizures (197/250,79%). CONCLUSIONS: Our study suggests that different seizure types have specific patterns in the Persyst QEEG spectrograms. Identifying these patterns in the EEG can significantly increase the sensitivity for seizure identification.

Assessing quantitative EEG spectrograms to identify non-epileptic events.

To evaluate the sensitivity and specificity of quantitative EEG (QEEG) spectrograms in order to distinguish epileptic from non-epileptic events. Seventeen patients with paroxysmal non-epileptic events, captured during EEG monitoring, were retrospectively assessed using QEEG spectrograms. These patients were compared to a control group of 13 consecutive patients (ages 25-60 years) with epileptic seizures of similar semiology. Assessment of raw EEG was employed as the gold standard against which epileptic and non-epileptic events were validated. QEEG spectrograms, available using Persyst 12 EEG system integration software, were each assessed with respect to their usefulness to distinguish epileptic from non-epileptic seizures. The given spectrogram was interpreted as indicating a seizure if, at the time of the clinically identified event, it showed a visually significant change from baseline. Eighty-two clinically identified paroxysmal events were analysed (46 non-epileptic and 36 epileptic). The "seizure detector trend analysis" spectrogram correctly classified 33/46 (71%) non-epileptic events (no seizure indicated during a clinically identified event) vs. 29/36 (81%) epileptic seizures (seizure indicated during a clinically identified event) (p=0.013). Similarly, "rhythmicity spectrogram", FFT spectrogram, "asymmetry relative spectrogram", and integrated-amplitude EEG spectrogram detected 28/46 (61%), 30/46 (65%), 22/46 (48%) and 27/46 (59%) non-epileptic events vs. 27/36 (75%), 25/36 (69%), 25/36 (69%) and 27/36 (75%) epileptic events, respectively. High sensitivities and specificities for QEEG seizure detection analyses suggest that QEEG may have a role at the bedside to facilitate early differentiation between epileptic seizures and non-epileptic events in order to avoid unnecessary administration of antiepileptic drugs and possible iatrogenic consequences.

Extended Clinical Spectrum of Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Children: A Case Series.

OBJECTIVE: There is a wide spectrum of clinical manifestations in children with anti-N-methyl-d-aspartate (NMDA) receptor antibody encephalitis from two different health care settings. METHODS: We describe our experience with 13 patients (median age, 7 years; range, 5 months to 19 years) presenting to tertiary referral centers in India and the United States. RESULTS: Initial manifestations were neurological (seizures or movement disorders) in eight patients, and psychiatric (e.g., emotional lability and hallucination) in five patients. Symptoms during the clinical course included seizures in ten patients, movement disorders (dyskinesia and choreiform movements) in 11 patients, and behavioral changes (aggressiveness and insomnia) in ten patients. Concomitant infections (herpes simplex virus 1, tuberculous meningitis, and influenza A) were present in three patients. Analysis of the cerebrospinal fluid in all except two cases preceded by infection (herpes simplex virus encephalitis and tuberculous meningitis) was unremarkable. Treatment included intravenous immunoglobulin/methylprednisolone (11 patients), rituximab (eight patients), plasmapheresis (two patients), and cyclophosphamide (two patients). Six patients recovered completely. Two patients had mild residual neurological deficits, whereas four had severe residual neurological deficits. Two patients had profound autonomic instability, which was the cause of death for one of them. Two patients relapsed at two and six months after the initial recovery. CONCLUSIONS: We describe the differences and similarities of clinical presentation, test results, and response to treatment of children with anti-N-methyl-d-aspartate receptor encephalitis from India and the United States. Included is a description of one of the youngest patients with anti-N-methyl-d-aspartate receptor encephalitis (five months) and the first patient to be reported in association with tuberculous meningitis.

Attitudes toward depression among a sample of Muslim adolescents in the Midwestern United States.

BACKGROUND: Little is known about how Muslim youth in non-Muslim countries perceive depression and its treatment and prevention. OBJECTIVE: We investigated the barriers and suggest treatment models for depressive disorders in Muslim adolescents and young adults residing in the United States. METHODS: We conducted a thorough literature review to identify previous study on the beliefs of American Muslim adolescents about depression and its treatment. We identified the gaps and developed a survey to ascertain this information from American Muslim adolescents. RESULTS: The survey was administered to a convenience sample of 125 Muslim subjects (60.0% males) aged 14-21 years. The sample was ethnically diverse with Pakistani (44.8%) encompassing the majority of the sample. Most responders believed that recitation from the Koran relieves mental distress. Multiple linear regression analysis revealed that those who reported strong emotional support from parents or a greater acceptance of taking depression medication prescribed from a physician were more likely to accept a physician's diagnosis, whereas believing in prayer to heal depression was associated with a lower likelihood of the same. Youth were accepting of Internet and preventive approaches. CONCLUSION: Planning of culturally sensitive mental health services is useful to accommodate the needs of Muslim youth served by primary care physicians and mental health practitioners in the United States. Muslim adolescents tend to be more traditional with family, social, and religious values. This value system plays an important role in their likelihood of seeking and accepting professional help for depression.