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1.
Seizure ; 70: 90-96, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31323566

RESUMO

PURPOSE: To evaluate whether the onset of pediatric refractory status epilepticus (rSE) is related to time of day. METHOD: We analyzed the time of day for the onset of rSE in this prospective observational study performed from June 2011 to May 2019 in pediatric patients (1 month to 21 years of age). We evaluated the temporal distribution of pediatric rSE utilizing a cosinor analysis. We calculated the midline estimating statistic of rhythm (MESOR) and amplitude. MESOR is the estimated mean number of rSE episodes per hour if they were evenly distributed. Amplitude is the difference between MESOR and maximum rSE episodes/hour, or between MESOR and minimum rSE episodes/hour. We also evaluated the temporal distribution of time to treatment. RESULTS: We analyzed 368 patients (58% males) with a median (p25 - p75) age of 4.2 (1.3-9.7) years. The MESOR was 15.3 (95% CI: 13.9-16.8) and the amplitude was 3.2 (95% CI: 1.1-5.3), p = 0.0024, demonstrating that the distribution is not uniform, but better described as varying throughout the day with a peak in the morning (11am-12 pm) and trough at night (11 pm-12 am). The duration from rSE onset to application of the first non-benzodiazepine antiseizure medication peaked during the early morning (2am-3 am) with a minimum during the afternoon (2 pm-3 pm) (p = 0.0179). CONCLUSIONS: The distribution of rSE onset is not uniform during the day. rSE onset shows a 24-h distribution with a peak in the mid-morning (11am-12 pm) and a trough at night (11 pm-12am).

2.
Epilepsia ; 60(6): 1209-1220, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31111463

RESUMO

OBJECTIVE: Sudden unexpected death in epilepsy (SUDEP) is an important cause of mortality in epilepsy. However, there is a gap in how often providers counsel patients about SUDEP. One potential solution is to electronically prompt clinicians to provide counseling via automated detection of risk factors in electronic medical records (EMRs). We evaluated (1) the feasibility and generalizability of using regular expressions to identify risk factors in EMRs and (2) barriers to generalizability. METHODS: Data included physician notes for 3000 patients from one medical center (home) and 1000 from five additional centers (away). Through chart review, we identified three SUDEP risk factors: (1) generalized tonic-clonic seizures, (2) refractory epilepsy, and (3) epilepsy surgery candidacy. Regular expressions of risk factors were manually created with home training data, and performance was evaluated with home test and away test data. Performance was evaluated by sensitivity, positive predictive value, and F-measure. Generalizability was defined as an absolute decrease in performance by <0.10 for away versus home test data. To evaluate underlying barriers to generalizability, we identified causes of errors seen more often in away data than home data. To demonstrate how small revisions can improve generalizability, we removed three "boilerplate" standard text phrases from away notes and repeated performance. RESULTS: We observed high performance in home test data (F-measure range = 0.86-0.90), and low to high performance in away test data (F-measure range = 0.53-0.81). After removing three boilerplate phrases, away performance improved (F-measure range = 0.79-0.89) and generalizability was achieved for nearly all measures. The only significant barrier to generalizability was use of boilerplate phrases, causing 104 of 171 errors (61%) in away data. SIGNIFICANCE: Regular expressions are a feasible and probably a generalizable method to identify variables related to SUDEP risk. Our methods may be implemented to create large patient cohorts for research and to generate electronic prompts for SUDEP counseling.

3.
Epilepsy Res ; 149: 44-52, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30476812

RESUMO

AIMS: We aimed to classify ictal onset patterns (IOPs) in pediatric patients undergoing intracranial electroencephalography (IEEG) to guide surgery for refractory epilepsy. We aimed to determine if morphology of IOPs can predict surgical outcome. MATERIALS AND METHODS: We performed a retrospective review of pediatric patients who underwent epilepsy surgery guided by subdural IEEG from 2007 to 2016. IEEG seizures were reviewed by a blinded epileptologist. Data was collected on outcomes. RESULTS: Twenty-three patients with 784 seizures were included. Age at seizure onset was 0.2-11 (mean 4.3, standard deviation 3.2) years. Age at time of IEEG was 4-20 (mean 13.5, standard deviation 4.4) years. Five distinct IOPs were seen at seizure onset: A) Low voltage fast activity (LVFA) with spread to adjacent electrodes (n = 7 patients, 30%), B) Burst of LVFA followed by electrodecrement (n = 12 patients, 52%), C) Burst of rhythmic spike waves (RSW) followed by electrodecrement (n = 9 patients, 39%), D) RSW followed by LVFA (n = 7 patients, 30%), E) Rhythmic spikes alone (n = 10 patients, 43%). Twelve patients (52%) had the same IOP type with all seizures. When the area of the IOP was resected, 14 patients (61%) had Engel I outcomes. Patients who had LVFA seen within their predominant IOP type were more likely to have good surgical outcomes (odds ratio 7.50, 95% confidence interval 1.02-55.0, p = 0.05). Patients who had only one IOP type were more likely to have good outcomes than patients who had multiple IOP types (odds ratio 12.6, 95% confidence interval 1.19-134, p = 0.04). Patients who had LVFA in their predominant IOP type were older than patients who did not have LVFA (mean age 15.0 vs. 9.9 years, p = 0.02). CONCLUSIONS: LVFA at ictal onset and all seizures having the same IOP morphology are associated with increased likelihood of surgical success in children, but LVFA is less common in children who are younger at the time of IEEG.


Assuntos
Ondas Encefálicas/fisiologia , Eletrocorticografia/métodos , Epilepsia/cirurgia , /métodos , Espaço Subdural , Adolescente , Criança , Pré-Escolar , Epilepsia Resistente a Medicamentos/cirurgia , Eletrodos Implantados , Epilepsia/diagnóstico por imagem , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Estudos Retrospectivos , Espaço Subdural/diagnóstico por imagem , Espaço Subdural/fisiopatologia , Resultado do Tratamento , Adulto Jovem
4.
Pediatr Neurol ; 86: 33-41, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30075875

RESUMO

OBJECTIVE: We aimed to evaluate and compare the status epilepticus treatment pathways used by pediatric status epilepticus research group (pSERG) hospitals in the United States and the American Epilepsy Society (AES) status epilepticus guideline. METHODS: We undertook a descriptive analysis of recommended timing, dosing, and medication choices in 10 pSERG hospitals' status epilepticus treatment pathways. RESULTS: One pathway matched the timeline in the AES guideline; nine pathways described more rapid timings. All pathways matched the guideline's stabilization phase in timing and five suggested that first-line benzodiazepine (BZD) be administered within this period. For second-line therapy timing (initiation of a non-BZD antiepileptic drug within 20 to 40 minutes), one pathway matched the guideline; nine initiated the antiepileptic drug earlier (median 10 [range five to 15] minutes). Third-line therapy timings matched the AES guideline (40 minutes) in two pathways; eight suggested earlier timing (median 20 [range 15 to 30] minutes). The first-line BZD recommended in all hospitals was intravenous lorazepam; alternatives included intramuscular midazolam or rectal diazepam. In second-line therapy, nine pathways recommended fosphenytoin. For third-line therapy, eight pathways recommended additional boluses of second-line medications; most commonly phenobarbital. Two pathways suggested escalation to third-line medication; most commonly midazolam. We found variance in dosing for the following medications: midazolam as first-line therapy, fosphenytoin, and levetiracetam as second-line therapy, and phenobarbital as third-line therapy medications. CONCLUSIONS: The pSERG hospitals status epilepticus pathways are consistent with the AES status epilepticus guideline in regard to the choice of medications, but generally recommend more rapid escalation in therapy than the guideline.


Assuntos
Anticonvulsivantes/administração & dosagem , Tratamento de Emergência , Hospitalização , Estado Epiléptico/terapia , Adolescente , Criança , Pré-Escolar , Esquema de Medicação , Hospitais Pediátricos , Humanos , Lactente , Guias de Prática Clínica como Assunto , Sociedades Médicas , Estados Unidos
5.
Epilepsia Open ; 3(1): 91-97, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29588993

RESUMO

Identifying individuals with rare epilepsy syndromes in electronic data sources is difficult, in part because of missing codes in the International Classification of Diseases (ICD) system. Our objectives were the following: (1) to describe the representation of rare epilepsies in other medical vocabularies, to identify gaps; and (2) to compile synonyms and associated terms for rare epilepsies, to facilitate text and natural language processing tools for cohort identification and population-based surveillance. We describe the representation of 33 epilepsies in 3 vocabularies: Orphanet, SNOMED-CT, and UMLS-Metathesaurus. We compiled terms via 2 surveys, correspondence with parent advocates, and review of web resources and standard vocabularies. UMLS-Metathesaurus had entries for all 33 epilepsies, Orphanet 32, and SNOMED-CT 25. The vocabularies had redundancies and missing phenotypes. Emerging epilepsies (SCN2A-, SCN8A-, KCNQ2-, SLC13A5-, and SYNGAP-related epilepsies) were underrepresented. Survey and correspondence respondents included 160 providers, 375 caregivers, and 11 advocacy group leaders. Each epilepsy syndrome had a median of 15 (range 6-28) synonyms. Nineteen had associated terms, with a median of 4 (range 1-41). We conclude that medical vocabularies should fill gaps in representation of rare epilepsies to improve their value for epilepsy research. We encourage epilepsy researchers to use this resource to develop tools to identify individuals with rare epilepsies in electronic data sources.

6.
J Child Neurol ; 32(7): 630-637, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28359187

RESUMO

Epilepsy outcomes after therapeutic hypothermia for neonates with hypoxic-ischemic encephalopathy are understudied. The authors used multivariable logistic regression to predict epilepsy in neonates after selective head cooling. Sensitivity analyses used magnetic resonance imaging (MRI) and electroencephalogram (EEG) interpretations by different clinicians. Fifty neonates had 2-year follow-up. Nine developed epilepsy. Predictors included pH ≤6.8 on day of birth (adjusted odds ratio [OR] 19 [95% confidence interval (CI) 1-371]), burst suppression on EEG on day 4 (8.2 [1.3-59]), and MRI deep gray matter injury (OR 33 [2.4-460]). These factors stratify neonates into low (0-1 factors; 3% [0%-14%] risk), medium (2 factors; 56% [21%-86%] risk), and high-risk groups (3 factors; 100% [29%-100%] risk) for epilepsy. The stratification was robust to varying clinical interpretations of the MRI and EEG. Neonates with hypoxic-ischemic encephalopathy who undergo selective head cooling appear at risk of epilepsy if they have 2 to 3 identified factors. If validated, this rule may help counsel families and identify children for close clinical follow-up.


Assuntos
Encéfalo/diagnóstico por imagem , Epilepsia/etiologia , Cabeça , Hipotermia Induzida/métodos , Hipóxia-Isquemia Encefálica/complicações , Hipóxia-Isquemia Encefálica/terapia , Pré-Escolar , Eletroencefalografia , Epilepsia/diagnóstico por imagem , Feminino , Humanos , Hipóxia-Isquemia Encefálica/diagnóstico por imagem , Lactente , Recém-Nascido , Imagem por Ressonância Magnética , Masculino , Estudos Retrospectivos , Resultado do Tratamento
7.
Neurology ; 88(4): 386-394, 2017 Jan 24.
Artigo em Inglês | MEDLINE | ID: mdl-28011930

RESUMO

OBJECTIVE: To compare refractory convulsive status epilepticus (rSE) management and outcome in children with and without a prior diagnosis of epilepsy and with and without a history of status epilepticus (SE). METHODS: This was a prospective observational descriptive study performed from June 2011 to May 2016 on pediatric patients (1 month-21 years of age) with rSE. RESULTS: We enrolled 189 participants (53% male) with a median (25th-75th percentile) age of 4.2 (1.3-9.6) years. Eighty-nine (47%) patients had a prior diagnosis of epilepsy. Thirty-four (18%) patients had a history of SE. The time to the first benzodiazepine was similar in participants with and without a diagnosis of epilepsy (15 [5-60] vs 16.5 [5-42.75] minutes, p = 0.858). Patients with a diagnosis of epilepsy received their first non-benzodiazepine (BZD) antiepileptic drug (AED) later (93 [46-190] vs 50.5 [28-116] minutes, p = 0.002) and were less likely to receive at least one continuous infusion (35/89 [39.3%] vs 57/100 [57%], p = 0.03). Compared to patients with no history of SE, patients with a history of SE received their first BZD earlier (8 [3.5-22.3] vs 20 [5-60] minutes, p = 0.0073), although they had a similar time to first non-BZD AED (76.5 [45.3-124] vs 65 [32.5-156] minutes, p = 0.749). Differences were mostly driven by the patients with an out-of-hospital rSE onset. CONCLUSIONS: Our study establishes that children with rSE do not receive more timely treatment if they have a prior diagnosis of epilepsy; however, a history of SE is associated with more timely administration of abortive medication.


Assuntos
Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsia Resistente a Medicamentos/terapia , Estado Epiléptico/fisiopatologia , Estado Epiléptico/terapia , Adolescente , Anticonvulsivantes/uso terapêutico , Criança , Pré-Escolar , Epilepsia Resistente a Medicamentos/diagnóstico , Feminino , Hospitalização , Humanos , Lactente , Masculino , Estudos Prospectivos , Estado Epiléptico/diagnóstico , Tempo para o Tratamento , Resultado do Tratamento , Estados Unidos , Adulto Jovem
8.
Curr Neurol Neurosci Rep ; 16(10): 92, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-27595805

RESUMO

PURPOSE OF REVIEW: This article strives to review and summarize selected recent literature and topics contributing to a greater understanding of the diagnosis and treatments of neonatal seizures that have emerged in the past several years. RECENT FINDINGS: Continuous EEG is recommended as the gold standard for neonatal seizure monitoring as it can provide additional information that may stratify patients by etiology, as well as identify at-risk groups of newborns for neuromonitoring. Investigations are moving beyond traditional antiepileptic agents in search of treatments with better efficacy and with less concern for developmental effects. Targeted therapies for seizures resulting from particular genetic conditions are increasing, highlighting the importance of early genetic diagnosis. Better understanding of the risk of post-neonatal epilepsy based on etiology is emerging with new epidemiological studies. Evidence is growing for deleterious effects of seizures on outcomes, elevating the importance of seizure detection and effective treatment. Advances in utilization of continuous EEG monitoring have improved the accuracy of seizure detection and have identified at-risk groups of newborns for neuromonitoring. Ultimately, the goal in management of neonatal seizures is not only clinical stabilization in the acute period but also to influence neurodevelopmental outcome and modify the risk of future epilepsy.


Assuntos
Eletroencefalografia/métodos , Epilepsia/diagnóstico , Doenças do Recém-Nascido/diagnóstico , Monitorização Neurofisiológica/métodos , Epilepsia/terapia , Humanos , Recém-Nascido , Doenças do Recém-Nascido/terapia
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