Association of first antiseizure medication with acute health care utilization in a cohort of adults with newly diagnosed epilepsy.

OBJECTIVE: Epilepsy is primarily treated with antiseizure medications (ASMs). The recommendations for first ASM in newly diagnosed epilepsy are inconsistently followed, and we sought to examine whether nonrecommended first ASM was associated with acute care utilization. METHODS: We conducted a retrospective cohort study of adults (≥18 years old) with newly diagnosed epilepsy (identified using validated epilepsy/convulsion International Classification of Diseases, Clinical Modification codes) in 2015-2019, sampled from Marketscan's Commercial and Medicare Databases. Exposure of interest was receipt of a non-guideline-recommended ASM, and the primary outcome was acute care utilization (an emergency department visit or hospitalization after the first ASM claim). Descriptive statistics characterized covariates, and multivariable negative binominal regression models were built adjusting for age, sex, Elixhauser Comorbidity Index, comorbid neurologic disease (e.g., stroke), and ASM polypharmacy. RESULTS: Approximately 14 681 people with new epilepsy were prescribed an ASM within 1 year. The three most prescribed medications were levetiracetam (54%, n = 7912), gabapentin (10%, n = 1462), and topiramate (7%, n = 1022). Approximately 4% (n = 648) were prescribed an ASM that should be avoided, and ~74% of people with new epilepsy had an acute care visit during the follow-up period. Mean number of acute care visits during follow-up was 3.34 for "recommended" ASMs and 4.42 for ASMs that "should be avoided." Prescription of a recommended/neutral ASM as compared to an ASM that should be avoided was associated with reduced likelihood of acute care utilization (incidence rate ratio [IRR] = .85, 95% confidence interval [CI] = .77-.94). The recommended/neutral category of ASMs was not statistically significantly associated with seizure- or epilepsy-specific acute care utilization (IRR = .93, 95% CI = .79-1.09). SIGNIFICANCE: Adults with new epilepsy are frequent users of acute care. There remain a proportion of persons with epilepsy prescribed ASMs that guidelines suggest avoiding, and these ASMs are associated with increased likelihood of emergency department visit or hospitalization. These findings reinforce the importance of optimizing the choice of first ASM in epilepsy.

Public access defibrillator locations and details in Forsyth County, North Carolina: Results of a telephone survey canvas of large businesses to facilitate out-of-hospital cardiac arrest treatment.

BACKGROUND: Limited data are available on locations of public access defibrillation programs across communities in the United States, despite their widespread presence. Our goal was to determine publicly available AED locations of large businesses in a mixed urban-rural county. We then compared our survey results to a NC state-mandated AED registry and the county's emergency medical dispatch center AED registry. METHODS: We conducted structured phone surveys of all large businesses (>19 employees) and select small businesses (healthcare, government, childcare, educational, and religious organizations with 1-19 employees) in Forsyth County, NC (n = 1702) to determine AED ownership and location. In addition, AED lists were elicited from multi-building organizations (e.g., health systems, universities, and local government), the NC Office of Emergency Medical Services (OEMS), and the Forsyth County emergency medical dispatch center. RESULTS: Our survey yielded a response rate of 79.1 % and identified 411 businesses with ≥ 1 AEDs. An additional 162 AED locations were contained in AED lists from multi-building organizations and registries. In total, our canvas identified 963 AEDs at 573 unique locations. The majority of AEDs (65.1 % [627/963]) were not previously registered in the NC OEMS AED registry. Few identified AEDs (11.8 % [114/963]) were listed in the county emergency medical dispatch center registry.

Drones reduce the time to defibrillation in a highly visited non-urban area: A randomized simulation-based trial.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) has a high global incidence and mortality rate, with early defibrillation significantly improving survival. Our aim was to assess the feasibility of autonomous drone delivery of automated external defibrillators (AED) in a non-urban area with physical barriers and compare the time to defibrillate (TTD) with bystander retrieval from a public access defibrillator (PAD) point and helicopter emergency medical services (HEMS) physician performed defibrillation. METHODS: This randomized simulation-based trial with a cross-over design included bystanders performing AED retrievals either delivered by automated drone flight or on foot from a PAD point, and simulated HEMS interventions. The primary outcome was the time to defibrillation, with secondary outcomes comparing workload, perceived physical effort, and ease of use. RESULTS: Thirty-six simulations were performed. Drone-delivered AED intervention had a significantly shorter TTD [2.2 (95 % CI 2.0-2.3) min] compared to PAD retrieval [12.4 (95 % CI 10.4-14.4) min] and HEMS [18.2 (95 % CI 17.1-19.2) min]. The self-reported physical effort on a visual analogue scale for drone-delivered AED was significantly lower versus PAD [2.5 (1 - 22) mm vs. 81 (65-99) mm, p = 0.02]. The overall mean workload measured by NASA-TLX was also significantly lower for drone delivery compared to PAD [4.3 (1.2-11.7) vs. 11.9 (5.5-14.5), p = 0.018]. CONCLUSION: The use of drones for automated AED delivery in a non-urban area with physical barriers is feasible and leads to a shorter time to defibrillation. Drone-delivered AEDs also involve a lower workload and perceived physical effort than AED retrieval on foot.

Prognostic interictal electroencephalographic biomarkers and models to assess antiseizure medication efficacy for clinical practice: A scoping review.

Antiseizure medication (ASM) is the primary treatment for epilepsy. In clinical practice, methods to assess ASM efficacy (predict seizure freedom or seizure reduction), during any phase of the drug treatment lifecycle, are limited. This scoping review identifies and appraises prognostic electroencephalographic (EEG) biomarkers and prognostic models that use EEG features, which are associated with seizure outcomes following ASM initiation, dose adjustment, or withdrawal. We also aim to summarize the population and context in which these biomarkers and models were identified and described, to understand how they could be used in clinical practice. Between January 2021 and October 2022, four databases, references, and citations were systematically searched for ASM studies investigating changes to interictal EEG or prognostic models using EEG features and seizure outcomes. Study bias was appraised using modified Quality in Prognosis Studies criteria. Results were synthesized into a qualitative review. Of 875 studies identified, 93 were included. Biomarkers identified were classed as qualitative (visually identified by wave morphology) or quantitative. Qualitative biomarkers include identifying hypsarrhythmia, centrotemporal spikes, interictal epileptiform discharges (IED), classifying the EEG as normal/abnormal/epileptiform, and photoparoxysmal response. Quantitative biomarkers were statistics applied to IED, high-frequency activity, frequency band power, current source density estimates, pairwise statistical interdependence between EEG channels, and measures of complexity. Prognostic models using EEG features were Cox proportional hazards models and machine learning models. There is promise that some quantitative EEG biomarkers could be used to assess ASM efficacy, but further research is required. There is insufficient evidence to conclude any specific biomarker can be used for a particular population or context to prognosticate ASM efficacy. We identified a potential battery of prognostic EEG biomarkers, which could be combined with prognostic models to assess ASM efficacy. However, many confounders need to be addressed for translation into clinical practice.

Psychoses after an antiepileptic drug administration: Frequency, timing, and duration.

OBJECTIVES: To clarify the pathophysiology of psychoses after the new administration of antiepileptic drugs (AED), we analyzed the annual incidence, timing of development, and duration of episodes. METHODS: Psychotic outcomes in the first 6-month period after an AED or non-AED administration in patients with focal epilepsy were exhaustively reviewed in eight Japanese neuropsychiatry institutions. In cases with psychotic episodes, the subtype of psychosis, timing of development, previous history of psychosis, and duration of the episode were evaluated. RESULTS: Between 1981 and 2015, 5018 new drugs (4402 AED and 616 non-AED) were administered to 2067 patients with focal epilepsy. In the first 6-month period, 105 psychotic episodes occurred (81 interictal psychosis [IIP] and 24 postictal psychosis). Furthermore, 55 cases were first episodes and 50 were recurrent episodes. The frequency of psychoses is significantly higher after AED administration (n = 102) compared with non-AED administration (n = 3). Psychosis occurred most frequently in the initial 1-month period after new-AED administration and tended to decrease with increasing time. The estimated annual incidence of all psychoses after a new AED administration was 3.5% (2.0% for first-episode psychosis and 1.8% for first-episode IIP). Duration of psychoses (mean, 38.5 weeks) was equivalent to overall IIP. Duration of IIP did not shorten with discontinuation of newly administered AED. SIGNIFICANCE: Patients with epilepsy exhibit psychosis more frequently after new AED administration than after non-AED administration. This study shows the pathophysiology of psychoses after AED administration with annual incidence, the timing of development, and the duration of PAP, which have rarely been reported.

Finnish parliament ASR corpus: Analysis, benchmarks and statistics.

Public sources like parliament meeting recordings and transcripts provide ever-growing material for the training and evaluation of automatic speech recognition (ASR) systems. In this paper, we publish and analyse the Finnish Parliament ASR Corpus, the most extensive publicly available collection of manually transcribed speech data for Finnish with over 3000 h of speech and 449 speakers for which it provides rich demographic metadata. This corpus builds on earlier initial work, and as a result the corpus has a natural split into two training subsets from two periods of time. Similarly, there are two official, corrected test sets covering different times, setting an ASR task with longitudinal distribution-shift characteristics. An official development set is also provided. We developed a complete Kaldi-based data preparation pipeline and ASR recipes for hidden Markov models (HMM), hybrid deep neural networks (HMM-DNN), and attention-based encoder-decoders (AED). For HMM-DNN systems, we provide results with time-delay neural networks (TDNN) as well as state-of-the-art wav2vec 2.0 pretrained acoustic models. We set benchmarks on the official test sets and multiple other recently used test sets. Both temporal corpus subsets are already large, and we observe that beyond their scale, HMM-TDNN ASR performance on the official test sets has reached a plateau. In contrast, other domains and larger wav2vec 2.0 models benefit from added data. The HMM-DNN and AED approaches are compared in a carefully matched equal data setting, with the HMM-DNN system consistently performing better. Finally, the variation of the ASR accuracy is compared between the speaker categories available in the parliament metadata to detect potential biases based on factors such as gender, age, and education.

Automated external defibrillators delivered by drones to patients with suspected out-of-hospital cardiac arrest.

AIMS: Early defibrillation is critical for the chance of survival in out-of-hospital cardiac arrest (OHCA). Drones, used to deliver automated external defibrillators (AEDs), may shorten time to defibrillation, but this has never been evaluated in real-life emergencies. The aim of this study was to investigate the feasibility of AED delivery by drones in real-life cases of OHCA. METHODS AND RESULTS: In this prospective clinical trial, three AED-equipped drones were placed within controlled airspace in Sweden, covering approximately 80 000 inhabitants (125 km2). Drones were integrated in the emergency medical services for automated deployment in beyond-visual-line-of-sight flights: (i) test flights from 1 June to 30 September 2020 and (ii) consecutive real-life suspected OHCAs. Primary outcome was the proportion of successful AED deliveries when drones were dispatched in cases of suspected OHCA. Among secondary outcomes was the proportion of cases where AED drones arrived prior to ambulance and time benefit vs. ambulance. Totally, 14 cases were eligible for dispatch during the study period in which AED drones took off in 12 alerts to suspected OHCA, with a median distance to location of 3.1 km [interquartile range (IQR) 2.8-3.4). AED delivery was feasible within 9 m (IQR 7.5-10.5) from the location and successful in 11 alerts (92%). AED drones arrived prior to ambulances in 64%, with a median time benefit of 01:52 min (IQR 01:35-04:54) when drone arrived first. In an additional 61 test flights, the AED delivery success rate was 90% (55/61). CONCLUSION: In this pilot study, we have shown that AEDs can be carried by drones to real-life cases of OHCA with a successful AED delivery rate of 92%. There was a time benefit as compared to emergency medical services in cases where the drone arrived first. However, further improvements are needed to increase dispatch rate and time benefits. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT04415398.

The association between the experience of lay responders and response interval to medical emergencies in a rural area: an observational study.

AIM: The aim of this retrospective observational study was to determine how response intervals correlated to the experience of the community first responders (CFRs) using data collected from the Danish Island of Langeland via a global positioning system (GPS)-based system. METHODS: All medical emergency calls involving CFRs in the time period from 21st of April 2012 to 31st of December 2017 were included. Each emergency call activated 3 CFRs. Response intervals were calculated using the time from when the system alerted the CFRs to CFR time of arrival at the emergency site measured by GPS. CFRs response intervals were grouped depending on their level of experience according to ≤ 10, 11-24, 25-49, 50-99, ≥ 100 calls accepted and arrived on-site. RESULTS: A total of 7273 CFR activations were included. Median response interval for the CFR arriving first on-site (n = 3004) was 4:05 min (IQR 2:42-6:01) and median response interval for the arrival of the CFR with an automated external defibrillator (n = 2594) was 5:46 min (IQR 3:59-8:05). Median response intervals were 5:53 min (3:43-8:29) for ≤ 10 calls (n = 1657), 5:39 min (3:49-8:01) for 11-24 calls (n = 1396), 5:45 min (3:49-8:00) for 25-49 calls (n = 1586), 5:07 min (3:38-7:26) for 50-99 calls (n = 1548) and 4:46 min (3:14-7:32) for ≥ 100 calls (n = 1086) (p < 0.001). There was a significant negative correlation between experience and response intervals (p < 0.001, Spearman's rho = -0.0914). CONCLUSION: This study found an inverse correlation between CFR experience and response intervals, which could lead to increased survival after a time-critical incident.

SERS Detection of the Anti-Epileptic Drug Perampanel in Human Saliva.

Surface-Enhanced Raman Scattering (SERS) can obtain the spectroscopic response of specific analytes. In controlled conditions, it is a powerful quantitative technique. However, often the sample and its SERS spectrum are complex. Pharmaceutical compounds in human biofluids with strong interfering signals from proteins and other biomolecules are a typical example. Among the techniques for drug dosage, SERS was reported to detect low drug concentrations, with analytical capability comparable to that of the assessed High-Performance Liquid Chromatography. Here, for the first time, we report the use of SERS for Therapeutic Drug Monitoring of the Anti-Epileptic Drug Perampanel (PER) in human saliva. We used inert substrates decorated with gold NPs deposited via Pulsed Laser Deposition as SERS sensors. We show that it is possible to detect PER in saliva via SERS after an optimized treatment of the saliva sample. Using a phase separation process, it is possible to extract all the diluted PER in saliva from the saliva phase to a chloroform phase. This allows us to detect PER in the saliva at initial concentrations of the order of 10-7 M, thus approaching those of clinical interest.

Preoperative antiepileptic drug prophylaxis for early postoperative seizures in supratentorial meningioma: a single-center experience.

OBJECTIVE: Perioperative antiepileptic drug (AED) prophylaxis for early postoperative seizures (EPSs) in patients with supratentorial meningiomas without preoperative seizures is controversial. This paper discusses the incidence, risk factors, control rate and AED withdrawal indications of EPS in patients undergoing supratentorial convexity and parasagittal/falx meningioma resection without preoperative seizures. METHODS: Patients treated for a histologically confirmed supratentorial convexity and parasagittal/falx meningioma at the authors' institution between 2015 and 2021 were retrospectively examined. Clinical and imaging data were assessed. Variates were analyzed using univariate and multivariate regression analyses. A PubMed review of the literature published between 2011 and 2021 was performed. RESULTS: In total, 517 patients met the selection criteria. EPS (within the first postoperative week) was observed in 30/517 cases (5.8%). Multivariate analysis revealed that surgical/medical complications (OR 16.33, 95% CI 7.07-37.7, P < 0.001) were the only independent predictors of EPS. The dose of valproic was increased and levetiracetam was added based on the frequency of seizures (≤ 2, > 2 times and status epilepticus). EPS control rates were 94.1% (16/17) and 92.3% (12/13), respectively. AEDs were discontinued at 2 weeks and 4-6 weeks, respectively. The authors identified 10 relevant studies in the literature. Based on their review of the literature, the incidence of EPS was 3.7% (47/1282) with AED use and 6.2% (95/1525) without AED use patients in supratentorial meningiomas without preoperative seizures. The incidence of EPS was 9.0% (19/209) in patients without AED use with convexity and parasagittal/falx meningiomas without preoperative seizures. CONCLUSIONS: AED prophylaxis can reduce the incidence of EPS in patients with convexity and parasagittal/falx meningiomas without preoperative seizures. Avoiding postoperative complications is an important means to prevent EPS. Combined medication has a significant effect on controlling repeated EPS. The timing of AED withdrawal was evaluated according to the clinical symptoms and imaging findings.

Impact of the COVID-19 Pandemic on Prehospital Intervention and Survival of Patients With Out-of-Hospital Cardiac Arrest in Osaka City, Japan.

BACKGROUND: The coronavirus disease (COVID-19) pandemic may have influenced the prehospital emergency care and deaths of individuals experiencing an out-of-hospital cardiac arrest (OHCA).Methods and Results: We analyzed the registry data of 2,420 and 2,371 OHCA patients in Osaka City, Japan in 2019 and 2020, respectively, according to the 3 waves of the COVID-19 pandemic. Patient outcomes were compared using multivariable logistic regression analyses with the 2019 data as the reference. Bystander cardiopulmonary resuscitation (CPR) was initiated significantly less frequently in 2020 than in 2019 (2019: 48.0%, 2020: 42.7%, P<0.001), particularly during the first wave (2019: 47.2%, 2020: 42.9%, P=0.046) and second wave (2019: 48.1%, 2020: 41.2%, P=0.010), but not during the third wave (2019: 49.2%, 2020: 44.1%, P=0.066). The public-access automated external defibrillator was less frequently applied during the first wave (2019: 12.6%, 2020: 9.9%, P=0.043), with no significant difference during the second wave (2019: 12.5%, 2020: 12.8%, P=0.863) and third wave (2019: 13.7%, 2020: 13.0%, P=0.722). There was a significant difference in 1-month survival with favorable neurological outcomes (2019: 4.6%, 2020: 3.3%, P=0.018), with a 28% reduction in the adjusted odds ratio in 2020 (0.72; 95% confidence interval: 0.52-0.99, P=0.044). CONCLUSIONS: Bystander CPR and neurologically favorable outcomes after OHCA decreased significantly during the COVID-19 pandemic in Japan.

Differences in aggression as psychiatric side effect of levetiracetam and perampanel in patients with epilepsy.

PURPOSE: Aggression is the most commonly encountered antiepileptic-drug (AED)-induced psychiatric adverse effects. Levetiracetam (LEV) is well known to be associated with increased rates of aggression, while perampanel (PER) is also recognized as a potentially aggression-promoting agent, though opinions vary. However, few studies have addressed questions regarding whether the nature of irritability-aggression differs between those drugs. The present study used a standardized rating scale to examine aggression among patient with epilepsy who received LEV or PER using specific measures to confirm the effects of the drugs. METHODS: We enrolled 144 consecutive outpatients receiving treatment for epilepsy with LEV (n = 103) or PER (n = 41), and determined their effects regarding aggression using the Buss-Perry Aggression Questionnaire (BAQ). For analysis, total BAQ scores for the LEV and PER subjects were compared to determine whether the aggression-promoting effects of the agents differed, and which BAQ subdomains (physical aggression, verbal aggression, anger, hostility) were related to production of aggression in patients taking either LEV or PER. As a subsidiary analysis, clinical variables inclusive of administered AED type that showed a significant impact on BAQ scores were determined. RESULTS: The LEV group had a significantly higher hostility score (19.4 ±â€¯5.8) as compared to the PER group (17.2 ±â€¯6.3) in subscale analysis (p < 0.05). In multiple regression analysis, LEV had a significant association with higher hostility score (P = 0.006). CONCLUSION: Our results indicate that while easily visible outward-directed aggression tends to be dominant in patients given PER, aggression provoked by LEV may be felt more subjectively or in an inward-directed manner, which can lead to more diverse expression and misrecognition.

A case of febrile infection-related epilepsy syndrome (FIRES) in young adult: still a diagnostic and therapeutic challenge.

A new onset of status epilepticus in a previously healthy adult preceded by a recent minor febrile infection represents a diagnostic and therapeutic challenge in clinical practice. Considering the broad spectrum of epileptic encephalopathies caused by autoimmune mechanisms, differential diagnosis for new-onset refractory status epilepticus (NORSE) should include febrile infection-related epilepsy syndrome (FIRES), in order to not underestimate the underlying etiological condition triggering epilepsy in non-epileptic patients (Hon et al. in Recent Pat Inflamm Allergy Drug Discov 12:128-135, 2018). We report a case of acute encephalopathy with refractory seizures after a febrile illness (FIRES) in a young adult with complete remission of symptoms as well as dramatic improvement of EEG abnormalities following intravenous immunoglobulin and proper antiepileptic medications. We conducted an extensive workup including lumbar puncture, blood tests, EEG serial monitoring, MRI brain, total body CT scan, and PET brain with FDG to shed light on the etiology of the disease.

Better outcomes from exercise-related out-of-hospital cardiac arrest in males and in the young: findings from the Swedish Registry of Cardiopulmonary Resuscitation.

BACKGROUND: Survival from out-of-hospital cardiac arrest (OHCA) is higher if the arrest is witnessed and occurs during exercise, however, there is contradicting data on prognosis with regards to sex and age. The purpose of this study was to compare the outcomes and circumstances of exercise-related OHCA in different age groups and between sexes in a large unselected population. METHODS: Data from exercise-related OHCAs reported to the Swedish Registry of Cardiopulmonary Resuscitation from 2011 to 2014 and from 2016 to 2018 were analysed. All cases of exercise-related OHCA in which emergency medical services attempted resuscitation were included. The primary outcome was survival to 30 days. RESULTS: In total, 635 cases of exercise-related OHCA outside of the home were identified. The overall 30-day survival rate was 44.5% with highest survival rate in the age group 0-35 years, compared with 36-65 years and >65 years (59.6% vs 46.0% and 40.4%, p=0.01). A subgroup analysis of 0-25 years showed a survival rate of 68.8%. Exercise-related OHCA in females (9.1% of total) were witnessed to a lower extent (66.7% vs 79.6%, p=0.03) and median time to cardiopulmonary resuscitation (CPR) was longer (2.0 vs 1.0 min, p=0.001) than in males. Females also had lower rates of ventricular fibrillation (43.4% vs 64.7%, p=0.003) and a lower 30-day survival rate (29.3% vs 46.0%, p=0.02). CONCLUSION: In exercise-related OHCA, younger victims have a higher survival rate. Exercise-related OHCA in females was rare, however, survival rates were lower compared with males and partly explained by a lower proportion of witnessed events, longer time to CPR and lower frequency of a shockable rhythm.

AEDNav: indoor navigation for locating automated external defibrillator.

BACKGROUND: In a sudden cardiac arrest, starting CPR and applying an AED immediately are the two highest resuscitation priorities. Many existing mobile applications have been developed to assist users in locating a nearby AED. However, these applications do not provide indoor navigation to the AED location. The time required to locate an AED inside a building due to a lack of indoor navigation systems will reduce the patient's chance of survival. The existing indoor navigation solutions either require special hardware, a large dataset or a significant amount of initial work. These requirements make these systems not viable for implementation on a large-scale. METHODS: The proposed system collects Wi-Fi information from the existing devices and the path's magnetic information using a smartphone to guide the user from a starting point to an AED. The information collected is processed using four techniques: turn detection method, Magnetic data pattern matching method, Wi-Fi fingerprinting method and Closest Wi-Fi location method to estimate user location. The user location estimations from all four techniques are further processed to determine the user's location on the path, which is then used to guide the user to the AED location. RESULTS: The four techniques used in the proposed system Turn detection, Magnetic data pattern matching, Closest Wi-Fi location and Wi-Fi fingerprinting can individually achieve the accuracy of 80% with the error distance ± 9.4 m, ± 2.4 m, ± 4.6 m, and ± 4.6 m respectively. These four techniques, applied individually, may not always provide stable results. Combining these techniques results in a robust system with an overall accuracy of 80% with an error distance of ± 2.74 m. In comparison, the proposed system's accuracy is higher than the existing systems that use Wi-Fi and magnetic data. CONCLUSION: This research proposes a novel approach that requires no special hardware, large scale data or significant initial work to provide indoor navigation. The proposed system AEDNav can achieve an accuracy similar to the existing indoor navigation systems. Implementing this indoor navigation system could reduce the time to locate an AED and ultimately increase patient survival during sudden cardiac arrest.

The Use of Antiepileptic Drugs During Pregnancy and Fetal Outcomes.

Epilepsy affects approximately 1 percent of the population and roughly 1 million women of childbearing age. Estimates suggest that 0.3-0.7 percent of pregnancies occur in women with epilepsy. Epilepsy itself increases the risk of congenital malformation and medications add to this risk. Also, approximately one-half of the use of medications for epilepsy are used for other indications, possibly increasing exposure in some women. As controlled trials with these medications are not performed during pregnancy, data has been accumulated primarily through databases and case studies. This review is intended to update the practitioner about the use and concerns of antiepileptic medications in the presnant woman and the potential effects on the fetus and neonate.

[Implementation of a smartphone-based first-responder alerting system]. / Implementierungsprozess einer Smartphone-basierten Ersthelferalarmierung: Herausforderungen bei der Einführung, Weiterentwicklung zum System 2.0.

Background: Shortening the resuscitation-free interval in cardiac arrest increases the survival rate. Smartphone-based systems can locate and alert nearby rescuers. Objectives: Implementation of a first responder system, technical development and adaption to regional structures. Materials and methods: The system "Region der Lebensretter" was successfully established in July 2018 in Freiburg. The need of optimization was evaluated every half year and realized according to the PDCA (plan-do-check-act) cycle. The necessary functions were specified (plan), programmed, tested and released (do). Afterwards the changes were evaluated (check) and, if necessary, further optimizations were implemented (act). Results: The number of registered rescuers increased from 276 (2nd half year 2018) to 794 (1st half year 2020). The rate of alarm acceptance increased from 30% (2nd half year 2018) to 49% (1st half year 2020). The following features were designed and released: dynamic adjustment of the alarm radius (DAA), critical alert function, connection to automated external defibrillator (AED) database, digital rescuer identification (ID), feedback button "arrived on scene", choice of means of transport for algorithm optimization. The number of existing AEDs increased from 190 to 270. Conclusion: The resuscitation-free interval can be shortened by smartphone-based alerting systems. For successful operation, the total number of rescuers and the technical realization is crucial. Further studies are necessary to investigate whether the survival rate of out-of-hospital cardiac arrest can be increased. It appears extremely appropriate to adapt these systems to databases of quality management or research registers.

Prediction of seizure recurrence risk following discontinuation of antiepileptic drugs.

OBJECTIVE: Discontinuation of antiepileptic drugs (AEDs) in seizure-free patients is an important goal because of possible long-term side effects and the social stigma burden of epilepsy. The purpose of this work was to assess seizure recurrence risk after suspension of AEDs, to evaluate predictors for recurrence, and to investigate the recovery of seizure control after relapse. In addition, the accuracy of a previously published prediction model of seizure recurrence risk was estimated. METHODS: Seizure-free patients with epilepsy who had discontinued AEDs were retrospectively enrolled. The frequency of seizure relapses after AED withdrawal as well as prognosis after recurrence were assessed and the predictive role of baseline clinical-demographic variables was evaluated. The aforementioned prediction model was also validated and its accuracy assessed at different seizure-relapse probability levels. RESULTS: The enrolled patients (n = 133) had been followed for a median of 3 years (range 0.8-33 years) after AED discontinuation; 60 (45%) of them relapsed. Previous febrile seizures in childhood (hazard ratio [HR] 3.927; 95% confidence interval [CI] 1.403-10.988), a seizure-free period on therapy of less than 2 years (HR 2.313; 95% CI 1.193-4.486), and persistent motor deficits (HR 4.568; 95% CI 1.412-14.772) were the clinical features associated with relapse risk in univariate analysis. Among these variables, only a seizure-free period on therapy of less than 2 years was associated with seizure recurrence in multivariate analysis (HR 2.365; 95% CI 1.178-4.7444). Pharmacological control of epilepsy was restored in 82.4% of the patients who relapsed. In this population, the aforementioned prediction model showed an unsatisfactory accuracy. SIGNIFICANCE: A period of freedom from seizure on therapy of less than 2 years was the main predictor of seizure recurrence. The accuracy of the previously described prediction tool was low in this cohort, thus suggesting its cautious use in real-world clinical practice.

Expert Opinion: Managing sleep disturbances in people with epilepsy.

Poor sleep and daytime sleepiness are common in people with epilepsy. Sleep disorders can disrupt seizure control and in turn sleep and vigilance problems can be exacerbated by seizures and by antiepileptic treatments. Nevertheless, these aspects are frequently overlooked in clinical practice and a clear agreement on the evidence-based guidelines for managing common sleep disorders in people with epilepsy is lacking. Recently, recommendations to standardize the diagnostic pathway for evaluating patients with sleep-related epilepsies and comorbid sleep disorders have been presented. To build on these, we adopted the Delphi method to establish a consensus within a group of experts and we provide practical recommendations for identifying and managing poor night-time sleep and daytime sleepiness in people with epilepsy. We recommend that a comprehensive clinical history of sleep habits and sleep hygiene should be always obtained from all people with epilepsy and their bed partners. A psychoeducational approach to inform patients about habits or practices that may negatively influence their sleep or their vigilance levels should be used, and strategies for avoiding these should be applied. In case of a suspected comorbid sleep disorder an appropriate diagnostic investigation should be performed. Moreover, the possible presence of sleep fragmentation induced by sleep-related seizures should be ruled out. Finally, the dose and timing of antiepileptic medications and other co-medications should be optimized to improve nocturnal sleep and avoid daytime sedation.

Aggression as psychiatric side effect of newer AEDs in patients with epilepsy: Cross-sectional study based on Buss-Perry Aggression Questionnaire.

PURPOSE: Aggression-irritability is the most commonly encountered antiepileptic-drug-induced psychiatric adverse effects. In this cross-sectional study, we tried to assess antiepileptic-drug-induced aggression in patients with epilepsy (PWE) with a standardized rating scale. METHODS: Two hundred sixty-six consecutive outpatients receiving treatment for epilepsy with antiepileptic drugs (AEDs) were initially examined, and the effects of the investigated drugs in regard to aggression were investigated using the Buss-Perry Aggression Questionnaire (BAQ). We compared BAQ scores as a function of a specific class of AEDs, levetiracetam (LEV), lacosamaide (LCM), perampanel (PER), and carbamazepine (CBZ), and determined whether AED type had a relationship with aggression. Additionally, the association of BAQ score with other clinico-demographic variables was also assessed. RESULTS: One-way ANOVA revealed that the LEV group had a significantly higher mean BAQ score as compared to the CBZ (P = 0.001) and LCM (P = 0.029) groups for total score. In subscale analysis, the LEV group had higher scores than the CBZ group for the physical aggression (p = 0.01), verbal aggression (p = 0.02) and hostility (p = 0.01) subscales, while the LEV group had a significantly higher mean score than the LCM group for hostility (p = 0.025). In multiple regression analysis, LEV had a statistically significant impact on increased total BAQ score (B = 0.119, p = 0.049). In contrast, CBZ (B = -0.191, p = 0.002), older age at epilepsy onset (B = -0.269, p = 0.000) and female gender (B = -0.210, p = 0.000) had a significant association with lower total BAQ score. CONCLUSIONS: Our results indicate that LEV is associated with increased aggression, while CBZ and LCM showed effects to reduce aggression.