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1.
Seizure ; 71: 295-303, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31518880

RESUMO

PURPOSE: Estimate the cost of status epilepticus (SE) admissions in the USA using claim databases based on ICD-10 codes. METHOD: Descriptive retrospective study using national estimates for the year 2016 from the KID's Inpatient Database (KID) for pediatric patients and from the National Inpatient Sample (NIS) for adults. These databases are comprehensive collections of all-payer, encounter-level hospital care data in the United States of America. RESULTS: From a population of 6,106,405 pediatric admissions there were 580 admissions related to SE. From a population of 29,274,158 adult admissions there were 1,405 admissions related to SE. The median (p25-p75) cost of pediatric admissions related to SE was $8,749 ($4,875-$19,067) in 2016 USA dollars [$9,295 ($5,180-$20,258) in inflation-adjusted 2019 USA dollars], and for adult admissions related to SE it was $14,678 ($7,203-$28,388) in 2016 USA dollars [$15,595 ($7,653-$30,161) in inflation-adjusted 2019 USA dollars]. Transforming to 2019 USA dollars, the values from the current study are consistent with prior estimates in the literature from the KID and NIS databases with a progressive increase, except for the cost of super-refractory SE in children that has increased disproportionately. CONCLUSIONS: This study estimates that the cost of admissions related to SE in the USA is approximately $9,000 in children and $15,000 in adults and shows that the cost estimates have not markedly changed with the advent of ICD-10.

2.
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).

3.
J Clin Neurophysiol ; 36(5): 365-370, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31166226

RESUMO

PURPOSE: We aimed to determine whether clinical EEG reports obtained from children in the intensive care unit with refractory status epilepticus could provide data for comparative effectiveness research studies. METHODS: We conducted a retrospective descriptive study to assess the documentation of key variables within clinical continuous EEG monitoring reports based on the American Clinical Neurophysiology Society's standardized EEG terminology for children with refractory status epilepticus from 10 academic centers. Two pediatric electroencephalographers reviewed the EEG reports. We compared reports generated using free text or templates. RESULTS: We reviewed 191 EEG reports. Agreement between the electroencephalographers regarding whether a variable was described in the report ranged from fair to very good. The presence of electrographic seizures (ES) was documented in 46% (87/191) of reports, and these reports documented the time of first ES in 64% (56/87), ES duration in 72% (63/85), and ES frequency in 68% (59/87). Reactivity was documented in 16% (31/191) of reports, and it was more often documented in template than in free-text reports (40% vs. 14%, P = 0.006). Other variables were not differentially reported in template versus free-text reports. CONCLUSIONS: Many key EEG features are not documented consistently in clinical continuous EEG monitoring reports, including ES characteristics and reactivity assessment. Standardization may be needed for clinical EEG reports to provide informative data for large multicenter observational studies.

4.
Neurology ; 92(20): e2339-e2348, 2019 05 14.
Artigo em Inglês | MEDLINE | ID: mdl-31068480

RESUMO

OBJECTIVE: Compare the cost and effectiveness of nonbenzodiazepine antiepileptic drugs (non-BZD AEDs) for treatment of BZD-resistant convulsive status epilepticus (SE). METHODS: Decision analysis model populated with effectiveness data from a systematic review and meta-analysis of the literature, and cost data from publicly available prices. The primary outcome was cost per seizure stopped ($/SS). Sensitivity analyses evaluated the robustness of the results across a wide variation of the input parameters. RESULTS: We included 24 studies with 1,185 SE episodes. The most effective non-BZD AED was phenobarbital (PB) with a probability of SS of 0.8 (95% confidence interval [CI]: 0.69-0.88), followed by valproate (VPA) (0.71 [95% CI: 0.61-0.79]), lacosamide (0.66 [95% CI: 0.51-0.79]), levetiracetam (LEV) (0.62 [95% CI: 0.5-0.73]), and phenytoin/fosphenytoin (PHT) (0.53 [95% CI: 0.39-0.67]). In pairwise comparisons, PB was more effective than PHT (p = 0.002), VPA was more effective than PHT (p = 0.043), and PB was more effective than LEV (p = 0.018). The most cost-effective non-BZD AED was LEV (incremental cost-effectiveness ratio [ICER]: $18.55/SS), followed by VPA (ICER: $94.44/SS), and lastly PB (ICER: $847.22/SS). PHT and lacosamide were not cost-effective compared to the other options. Sensitivity analyses showed marked overlap in cost-effectiveness, but PHT was consistently less cost-effective than LEV, VPA, and PB. CONCLUSION: VPA and PB were more effective than PHT for SE. There is substantial overlap in the cost-effectiveness of non-BZD AEDs for SE, but available evidence does not support the preeminence of PHT, neither in terms of effectiveness nor in terms of cost-effectiveness.

5.
Neurology ; 2019 Jan 04.
Artigo em Inglês | MEDLINE | ID: mdl-30610098

RESUMO

OBJECTIVE: To compare the cost-effectiveness of genetic testing strategies in patients with epilepsy of unknown etiology. METHODS: This meta-analysis and cost-effectiveness study compared strategies involving 3 genetic tests: chromosomal microarray (CMA), epilepsy panel (EP) with deletion/duplication testing, and whole-exome sequencing (WES) in a cost-effectiveness model, using "no genetic testing" as a point of comparison. RESULTS: Twenty studies provided information on the diagnostic yield of CMA (8 studies), EP (9 studies), and WES (6 studies). The diagnostic yield was highest for WES: 0.45 (95% confidence interval [CI]: 0.33-0.57) (0.32 [95% CI: 0.22-0.44] adjusting for potential publication bias), followed by EP: 0.23 (95% CI: 0.18-0.29), and CMA: 0.08 (95% CI: 0.06-0.12). The most cost-effective test was WES with an incremental cost-effectiveness ratio (ICER) of $15,000/diagnosis. However, after adjusting for potential publication bias, the most cost-effective test was EP (ICER: $15,848/diagnosis) followed by WES (ICER: $34,500/diagnosis). Among combination strategies, the most cost-effective strategy was WES, then if nondiagnostic, EP, then if nondiagnostic, CMA (ICER: $15,336/diagnosis), although adjusting for potential publication bias, the most cost-effective strategy was EP ± CMA ± WES (ICER: $18,385/diagnosis). While the cost-effectiveness of individual tests and testing strategies overlapped, CMA was consistently less cost-effective than WES and EP. CONCLUSION: WES and EP are the most cost-effective genetic tests for epilepsy. Our analyses support, for a broad population of patients with unexplained epilepsy, starting with these tests. Although less expensive, CMA has lower yield, and its use as the first-tier test is thus not supported from a cost-effectiveness perspective.

6.
Seizure ; 68: 16-21, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30170734

RESUMO

PURPOSE: To summarize the pathophysiology of convulsive status epilepticus (SE) with a focus on practical implications for treatment. METHOD: Narrative review of the medical literature on the pathophysiology of convulsive SE. We considered both animal models of SE and clinical studies. RESULTS: Convulsive SE is an emergency in which prolonged convulsive seizures are associated with cardiorespiratory instability, hypoxia, hypoglycemia, and hyperthermia. Supportive treatment helps correct these physiological imbalances. When treatment is delayed, the ability of first line seizure suppressing medications to terminate the seizure can be reduced. Animal studies have suggested that GABAA receptor trafficking may contribute to the failure of the first line therapies and that NMDA receptor antagonists such as ketamine may become more effective as seizures last longer. Potential strategies to take advantage of these changes in pathophysiology include a rapid escalation from benzodiazepines to non-benzodiazepine antiepileptic drugs (AEDs), early polytherapy and use of NMDA antagonists such as ketamine for refractory convulsive SE. Despite the importance of a timely treatment of convulsive SE, major treatment delays are frequent in clinical practice. Policies to improve time to treatment, especially in convulsive SE that starts outside the hospital, may improve response to treatment and convulsive SE outcomes. CONCLUSIONS: Convulsive SE is a time-sensitive emergency in which the underlying pathophysiology may provide targets for improving treatment strategies. A timely transition from benzodiazepines to other AEDs may help reduce treatment resistance in convulsive SE.

7.
Seizure ; 68: 79-88, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30473267

RESUMO

PURPOSE: Rescue medications for status epilepticus (SE) have a relatively high rate of failure. The purpose of this review is to summarize the evidence for the efficacy of novel drugs and early polypharmacotherapy for SE. METHOD: Literature review. RESULTS: New drugs and treatment strategies aim to target the pathophysiology of SE in order to improve seizure control and outcomes. Changes at the synapse level during SE include a progressive decrease in synaptic GABAA receptors and increase in synaptic NMDA receptors. These changes tend to promote self-sustaining seizures. Current SE guidelines recommend a rapid stepwise treatment using benzodiazepines in monotherapy as the first-line treatment, targeting GABAA synaptic receptors. Novel treatment approaches target GABAA synaptic and extrasynaptic receptors with allopregnanolone, and NMDA receptors with ketamine. Novel rescue treatments used for SE include topiramate, brivaracetam, and perampanel, which are already marketed in epilepsy. Some available drugs not marketed for use in epilepsy have been used in the treatment of SE, and other agents are being studied for this purpose. Early polytherapy, most frequently combining a benzodiazepine with a second-line drug or an NMDA receptor antagonist, might potentially increase seizure control with relatively minor increase in side effects. Although many preclinical studies support novel drugs and early polytherapy in SE, human studies are scarce and inconclusive. Currently, evidence is lacking to recommend specific combinations of these new agents. CONCLUSIONS: Novel drugs and strategies target the underlying pathophysiology of SE with the intent to improve seizure control and outcomes.

8.
Brain Res ; 1703: 3-12, 2019 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-29481793

RESUMO

BACKGROUND: The occurrence of epileptic seizures in seemingly random patterns takes a great toll on persons with epilepsy and their families. Seizure prediction may markedly improve epilepsy management and, therefore, the quality of life of persons with epilepsy. METHODS: Literature review. RESULTS: Seizures tend to occur following complex non-random patterns. Circadian oscillators may contribute to the rhythmic patterns of seizure occurrence. Complex mathematical models based on chaos theory try to explain and even predict seizure occurrence. There are several patterns of epileptic seizure occurrence based on seizure location, seizure semiology, and hormonal factors, among others. These patterns are most frequently described for large populations. Inter-individual variability and complex interactions between the rhythmic generators continue to make it more difficult to predict seizures in any individual person. The increasing use of large databases and machine learning techniques may help better define patterns of seizure occurrence in individual patients. Improvements in seizure detection -such as wearable seizure detectors- and in seizure prediction -such as machine learning techniques and artificial as well as neuronal networks- promise to provide further progress in the field of epilepsy and are being applied to closed-loop systems for the treatment of epilepsy. CONCLUSIONS: Seizures tend to occur following complex and patient-specific patterns despite their apparently random occurrence. A better understanding of these patterns and current technological advances may allow the implementation of closed-loop detection, prediction, and treatment systems in routine clinical practice.

9.
PLoS One ; 13(11): e0207491, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30458029

RESUMO

BACKGROUND: Tuberculosis is a major cause of morbidity and mortality in the developing world. Drug resistance, which is predicted to rise in many countries worldwide, threatens tuberculosis treatment and control. OBJECTIVE: To identify features associated with treatment failure and to predict which patients are at highest risk of treatment failure. METHODS: On a multi-country dataset managed by the National Institute of Allergy and Infectious Diseases we applied various machine learning techniques to identify factors statistically associated with treatment failure and to predict treatment failure based on baseline demographic and clinical characteristics alone. RESULTS: The complete-case analysis database consisted of 587 patients (68% males) with a median (p25-p75) age of 40 (30-51) years. Treatment failure occurred in approximately one fourth of the patients. The features most associated with treatment failure were patterns of drug sensitivity, imaging findings, findings in the microscopy Ziehl-Nielsen stain, education status, and employment status. The most predictive model was forward stepwise selection (AUC: 0.74), although most models performed at or above AUC 0.7. A sensitivity analysis using the 643 original patients filling the missing values with multiple imputation showed similar predictive features and generally increased predictive performance. CONCLUSION: Machine learning can help to identify patients at higher risk of treatment failure. Closer monitoring of these patients may decrease treatment failure rates and prevent emergence of antibiotic resistance. The use of inexpensive basic demographic and clinical features makes this approach attractive in low and middle-income countries.


Assuntos
Antituberculosos/uso terapêutico , Tuberculose Extensivamente Resistente a Medicamentos/epidemiologia , Previsões , Falha de Tratamento , Adulto , Antituberculosos/efeitos adversos , Tuberculose Extensivamente Resistente a Medicamentos/tratamento farmacológico , Tuberculose Extensivamente Resistente a Medicamentos/microbiologia , Tuberculose Extensivamente Resistente a Medicamentos/patologia , Feminino , Humanos , Aprendizado de Máquina , Masculino , Microscopia , Pessoa de Meia-Idade , Fatores de Risco , Máquina de Vetores de Suporte
11.
Seizure ; 61: 186-198, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30179844

RESUMO

PURPOSE: To estimate the cost of admissions related to status epilepticus (SE) in the USA and to evaluate SE mortality. METHOD: Descriptive retrospective study using national estimates from the KID's Inpatient Database (KID) for children and from the National Inpatient Sample (NIS) for adults for the years 2007-2012, the largest collection of all-payer, encounter-level hospital care data in the United States. The individual observation in this study is hospital admission. RESULTS: From a population of 186,013,640 admissions, a total of 184,500 admissions were related to SE. The median (p25-p75) cost of admissions related to SE was $7690 ($3893-$17,247) in the KID 2010-2012, $6529 ($3,370-$14,854) in the KID 2007-2009, $13,874 ($6699-$29,176) in the NIS 2012, $13,313 ($6,483-$28,598) in the NIS 2011, $12,999 ($6,366-$27,505) in the NIS 2010, $11,833 ($5721-$24,657) in the NIS 2009, $11,479 ($5,611-$24,326) in the NIS 2008, and $10,759 ($5493-$22,928) in the NIS 2007. Costs were more than two times higher for super-refractory SE admissions than for refractory SE admissions. Costs stratified by age followed an "U"-shaped distribution with higher costs in admissions of young children and older adults. Mortality ranged from 2.5% to 3% in children and from 12.7% to 14.9% in adults. CONCLUSIONS: This study estimates the cost of admissions related to SE in the USA to be approximately $7000 in children and $13,000 in adults, and quantifies how costs markedly increase once SE becomes super-refractory.


Assuntos
Custos de Cuidados de Saúde , Administração Hospitalar/economia , Estado Epiléptico/economia , Estado Epiléptico/epidemiologia , Adolescente , Distribuição por Idade , Criança , Pré-Escolar , Feminino , Administração Hospitalar/métodos , Humanos , Lactente , Recém-Nascido , Classificação Internacional de Doenças , Masculino , Estudos Retrospectivos , Estado Epiléptico/terapia , Estados Unidos/epidemiologia , Adulto Jovem
12.
Epilepsia ; 59 Suppl 2: 155-169, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30146786

RESUMO

We reviewed 37 studies reporting long-term outcomes after a status epilepticus (SE) episode in pediatric and adult populations. Study design, length of follow-up, outcome measures, domains investigated (mortality, SE recurrence, subsequent epilepsy, cognitive outcome, functional outcome, or quality of life), and predictors of long-term outcomes are summarized. Despite heterogeneity in the design of prior studies, overall risk of poor long-term outcome after SE is high in both children and adults. Etiology is the main determinant of outcome, and the effect of age or SE duration is often difficult to distinguish from the underlying cause. The effect of the treatment on long-term outcome after SE is still unknown.


Assuntos
Estado Epiléptico/complicações , Estado Epiléptico/etiologia , Estado Epiléptico/terapia , Resultado do Tratamento , Adulto , Fatores Etários , Criança , Pré-Escolar , Transtornos Cognitivos/etiologia , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Estudos Longitudinais , Masculino , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Qualidade de Vida , Estado Epiléptico/psicologia
13.
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
14.
J Child Neurol ; 33(8): 546-553, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29756499

RESUMO

The aim of this study was to evaluate the performance of models predicting in-hospital mortality in critically ill children undergoing continuous electroencephalography (cEEG) in the intensive care unit (ICU). We evaluated the performance of machine learning algorithms for predicting mortality in a database of 414 critically ill children undergoing cEEG in the ICU. The area under the receiver operating characteristic curve (AUC) in the test subset was highest for stepwise selection/elimination models (AUC = 0.82) followed by least absolute shrinkage and selection operator (LASSO) and support vector machine with linear kernel (AUC = 0.79), and random forest (AUC = 0.71). The explanatory models had the poorest discriminative performance (AUC = 0.63 for the model without considering etiology and AUC = 0.45 for the model considering etiology). Using few variables and a relatively small number of patients, machine learning techniques added information to explanatory models for prediction of in-hospital mortality.


Assuntos
Cuidados Críticos , Diagnóstico por Computador/métodos , Eletroencefalografia , Aprendizado de Máquina , Monitorização Neurofisiológica/métodos , Adolescente , Área Sob a Curva , Criança , Pré-Escolar , Cuidados Críticos/métodos , Eletroencefalografia/métodos , Epilepsia/diagnóstico , Epilepsia/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Masculino , Prognóstico , Convulsões/diagnóstico , Convulsões/mortalidade , Sensibilidade e Especificidade , Adulto Jovem
15.
JAMA Neurol ; 75(4): 410-418, 2018 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-29356811

RESUMO

Importance: Treatment delay for seizures can lead to longer seizure duration. Whether treatment delay is associated with major adverse outcomes, such as death, remains unknown. Objective: To evaluate whether untimely first-line benzodiazepine treatment is associated with unfavorable short-term outcomes. Design, Setting, and Participants: This multicenter, observational, prospective cohort study included 218 pediatric patients admitted between June 1, 2011, and July 7, 2016, into the 11 tertiary hospitals in the United States within the Pediatric Status Epilepticus Research Group. Patients, ranging in age from 1 month to 21 years, with refractory convulsive status epilepticus (RCSE) that did not stop after the administration of at least 2 antiseizure medications were included. Patients were divided into 2 cohorts: those who received the first-line benzodiazepine treatment in less than 10 minutes and those who received it 10 or more minutes after seizure onset (untimely). Data were collected and analyzed from June 1, 2011, to July 7, 2016. Main Outcomes and Measures: The primary outcome was death during the related hospital admission. The secondary outcome was the need for continuous infusion for seizure termination. Multivariate analysis of mortality controlled for structural cause, febrile RCSE, age, and previous neurological history (including previous RCSE events). Use of continuous infusions was additionally adjusted for generalized RCSE, continuous RCSE, and 5 or more administrations of antiseizure medication. Results: A total of 218 patients were included, among whom 116 (53.2%) were male and the median (interquartile range) age was 4.0 (1.2-9.6) years. The RCSE started in the prehospital setting for 139 patients (63.8%). Seventy-four patients (33.9%) received their first-line benzodiazepine treatment in less than 10 minutes, and 144 (66.1%) received untimely first-line benzodiazepine treatment. Multivariate analysis showed that patients who received untimely first-line benzodiazepine treatment had higher odds of death (adjusted odds ratio [AOR], 11.0; 95% CI, 1.43 to ∞; P = .02), had greater odds of receiving continuous infusion (AOR, 1.8; 95% CI, 1.01-3.36; P = .047), had longer convulsive seizure duration (AOR, 2.6; 95% CI, 1.38-4.88; P = .003), and had more frequent hypotension (AOR 2.3; 95% CI, 1.16-4.63; P = .02). In addition, the timing of the first-line benzodiazepine treatment was correlated with the timing of the second-line (95% CI, 0.64-0.95; P < .001) and third-line antiseizure medications (95% CI, 0.25-0.78; P < .001). Conclusions and Relevance: Among pediatric patients with RCSE, an untimely first-line benzodiazepine treatment is independently associated with a higher frequency of death, use of continuous infusions, longer convulsion duration, and more frequent hypotension. Results of this study raise the question as to whether poor outcomes could, in part, be prevented by earlier administration of treatment.


Assuntos
Anticonvulsivantes/uso terapêutico , Benzodiazepinas/uso terapêutico , Estado Epiléptico/tratamento farmacológico , Estado Epiléptico/mortalidade , Tempo para o Tratamento , Resultado do Tratamento , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Fatores de Tempo , Estados Unidos , Adulto Jovem
16.
Seizure ; 54: 19-26, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29182970

RESUMO

PURPOSE: Describe timing from intensive care unit (ICU) admission to initiation of continuous electroencephalogram (cEEG) in repeated ICU admissions. METHOD: We performed a retrospective observational study in pediatric patients who underwent repeated ICU admissions with cEEG from 2011 to 2013. The main outcome measure was time from ICU admission to cEEG. RESULTS: There were 41 patients (54% males) with at least 2 ICU admissions with cEEG (median (p25-p75) age at first admission: 3.3 (0.3-8.4) years, at second admission: 3.9 (1.1-9.4) years), 7 patients (57% males, 9.9 (2.9-11.5) years) with at least 3 ICU admissions, and 5 patients (60% males, 10.1 (4-10.5) years) with at least 4 ICU admissions. One patient had 21 ICU admissions. The median (p25-p75) time from ICU admission to cEEG was not different during the first and second ICU admissions [10.7 (1.9-22.9) hours versus 13 (0.2-36.7) hours; p=0.908]. Among patients with electrographic seizures on first admission, time to cEEG was not different during the first and second admissions [7.9 (0.5-23.4) hours versus 14.5 (-2 to 44.5) hours; p=0.636]. Among patients with status epilepticus during the first admission, time to cEEG was not different between the first and second admissions [15.3 (9-79) hours versus 40.7 (19.3-42.6) hours; p=0.75]. CONCLUSIONS: The time from ICU admission to the initiation of cEEG did not decrease in second or subsequent ICU admissions, even in patients with seizures or status epilepticus on the first admission.


Assuntos
Eletroencefalografia , Unidades de Terapia Intensiva Pediátrica , Convulsões/diagnóstico , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Fatores de Tempo
17.
Dev Med Child Neurol ; 60(3): 283-289, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29168169

RESUMO

AIM: To evaluate the efficacy of clobazam treatment in reducing epileptiform discharges and modifying neuropsychological function in continuous spike-wave during slow wave sleep. METHOD: We performed a prospective clinical trial in patients with continuous spike-wave during sleep aged 4 to 10 years. Patients underwent neuropsychological assessment and overnight electroencephalographic monitoring before treatment, and subsequent repeat assessment and overnight electroencephalographic monitoring 3 months after treatment. Treatment consisted of 1mg/kg clobazam up to a maximum dose of 30mg during the first night, followed by 0.5mg/kg nightly for 3 months. RESULTS: Nine patients completed the study and had pre- and post-neuropsychological evaluation. There was a qualitative reduction in median (p25 -p75 ) spike percentage after 3 months (72.2 [68.0-75.8] vs 32.7 [4.7-81.7]). There were no marked changes in median (p25 -p75 ) IQ comparing pre- and post-clobazam treatment (80.0 [74.0-88.0] vs 80.0 [67.0-89.0]). There was a qualitative increase in Verbal IQ (83.0 [69.0-92.0] vs 95.0 [83.0-99.0]) and a qualitative decrease in Non-verbal IQ (84.0 [74.0-87.0] vs 71.0 [60.0-84.0]). INTERPRETATION: Qualitative improvements in epileptiform activity and cognition occurred in patients treated with clobazam for 3 months and the relationship between epileptiform activity and cognitive outcome should be studied in larger studies. WHAT THIS PAPER ADDS: Verbal IQ in patients with continuous spike-wave during sleep improved following short-term treatment with clobazam. Other neuropsychological improvements were observed, but varied by patient. Cognitive improvement was observed despite some worsening of epileptiform discharges.


Assuntos
Benzodiazepinas/farmacologia , Benzodiazepinas/uso terapêutico , Ondas Encefálicas/efeitos dos fármacos , Cognição/efeitos dos fármacos , Epilepsia/tratamento farmacológico , Sono/efeitos dos fármacos , Adolescente , Criança , Pré-Escolar , Clobazam , Eletroencefalografia , Epilepsia/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Testes Neuropsicológicos , Estudos Prospectivos , Adulto Jovem
18.
Epilepsia ; 58(12): 2098-2103, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29105055

RESUMO

OBJECTIVE: The multicenter National Infantile Spasms Consortium prospective cohort was used to compare outcomes and phenotypic features of patients with infantile spasms with and without hypsarrhythmia. METHODS: Patients aged 2 months to 2 years were enrolled prospectively with new-onset infantile spasms. Treatment choice and categorization of hypsarrhythmia were determined clinically at each site. Response to therapy was defined as resolution of clinical spasms (and hypsarrhythmia if present) without relapse 3 months after initiation. RESULTS: Eighty-two percent of patients had hypsarrhythmia, but this was not associated with gender, mean age, preexisting developmental delay or epilepsy, etiology, or response to first-line therapy. Infants with hypsarrhythmia were more likely to receive standard treatment (adrenocorticotropic hormone, prednisolone, or vigabatrin [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.4-4.7] and preexisting epilepsy reduced the likelihood of standard treatment (OR 3.2, 95% CI 1.9-5.4). Hypsarrhythmia was not a determinant of response to treatment. A logistic regression model demonstrated that later age of onset (OR 1.09 per month, 95% CI 1.03-1.15) and absence of preexisting epilepsy (OR 1.7, 95% CI 1.06-2.81) had a small impact on the likelihood of responding to the first-line treatment. However, receiving standard first-line treatment increased the likelihood of responding dramatically: vigabatrin (OR 5.2 ,95% CI 2-13.7), prednisolone (OR 8, 95% CI 3.1-20.6), and adrenocorticotropic hormone (ACTH; OR 10.2, 95% CI 4.1-25.8) . SIGNIFICANCE: First-line treatment with standard therapy was by far the most important variable in determining likelihood of response to treatment of infantile spasms with or without hypsarrhythmia.


Assuntos
Espasmos Infantis/terapia , Hormônio Adrenocorticotrópico/uso terapêutico , Idade de Início , Anticonvulsivantes/uso terapêutico , Estudos de Coortes , Feminino , Humanos , Lactente , Masculino , Prednisolona/uso terapêutico , Cobertura de Condição Pré-Existente , Estudos Prospectivos , Fatores Sexuais , Espasmos Infantis/fisiopatologia , Resultado do Tratamento , Vigabatrina/uso terapêutico
19.
J Child Neurol ; 32(13): 1065-1073, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28925315

RESUMO

OBJECTIVE: To quantify the prognostic value of neonatal brain magnetic resonance imaging (MRI) in neonatal hypoxic-ischemic encephalopathy. METHODS: Meta-analysis of studies with ≥35-week neonates with hypoxic-ischemic encephalopathy who underwent brain MRI within age 4 weeks and had neurodevelopmental follow-up for at least 12 months. RESULTS: An abnormal neonatal brain MRI was more frequent among patients with unfavorable neurodevelopmental outcome: odds ratio = 18.2 (95% confidence interval: 9.4-34.9), P <.0001. The prognostic value of neonatal brain MRI in moderate hypoxic-ischemic encephalopathy had an odds ratio of 17.7 (95% confidence interval: 5.3-59.3) and in severe hypoxic-ischemic encephalopathy, the odds ratio was 125.0 (95% confidence interval: 2.0-7917.1). Therapeutic hypothermia did not change the prognostic value of neonatal brain MRI (odds ratio for hypothermia, 14.0 [95% confidence interval: 3.1-63.6], vs no hypothermia, 18.1 [95% confidence interval: 10.0-33.1], P = .7525). CONCLUSION: Neonatal brain MRI provides prognostic information on outcome beyond early infancy in hypoxic-ischemic encephalopathy and therapeutic hypothermia does not change its prognostic value.


Assuntos
Encéfalo/diagnóstico por imagem , Hipóxia-Isquemia Encefálica/diagnóstico por imagem , Imagem por Ressonância Magnética , Humanos , Hipóxia-Isquemia Encefálica/terapia , Recém-Nascido , Prognóstico
20.
J Neurol ; 264(8): 1735-1745, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28702686

RESUMO

The aim is to describe the epidemiology of epilepsy surgery in children and adults in the United States. We performed a descriptive study of the National Inpatient Sample (NIS) for the year 2012 and the Kids' Inpatient Database (KID) for the period 2010-2012, the largest all-payer databases on inpatient data in the USA. These databases estimate 97% of all inpatient hospital discharges in the USA. In the KID, 12,899 (0.2%) of admission records had brain surgery and 600 of the 4900 (12.2%) admissions with focal refractory epilepsy underwent epilepsy surgery. Epilepsy surgery occurred in 60% of Whites, 7% of Blacks, 15% of Hispanics, and 10% of other races. In the NIS, 99,650 (0.3%) of admission records had brain surgery and 1170 of the 9775 (12%) admissions with focal refractory epilepsy underwent epilepsy surgery. Epilepsy surgery occurred in 69% of Whites, 7% of Blacks, 9% of Hispanics, and 8% of other races. In both the KID and the NIS, lower socioeconomic status was mildly underrepresented in epilepsy surgery. In both pediatric and adult admissions, there was an overrepresentation of Whites and underrepresentation of Blacks, which persisted after stratifying by socioeconomic status. Females were underrepresented in epilepsy surgery, but gender disparities were partially explained by differences in socioeconomic status. Epilepsy surgery is not equally distributed across races in the USA and these differences are not fully attributable to differences in socioeconomic status. Racial disparities in epilepsy surgery similarly affect children and adults.


Assuntos
Epilepsia Resistente a Medicamentos/epidemiologia , Epilepsia Resistente a Medicamentos/cirurgia , Epilepsias Parciais/epidemiologia , Epilepsias Parciais/cirurgia , Disparidades em Assistência à Saúde/etnologia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Adulto Jovem
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