Emergency department seizure epidemiology

Development of clinical prediction model to guide the use of CT head scans for non-traumatic Thai patient with seizure: A cross-sectional study

The aim of this study was to develop clinical predictor tools for guiding the use of computed tomography (CT) head scans in non-traumatic Thai patients presented with seizure. A prediction model using a retrospective cross-sectional design was conducted. We recruited adult patients (aged ≥ 18 years) who had been diagnosed with seizures by their physicians and had undergone CT head scans for further investigation. Positive CT head defined as the presence of any new lesion that related to the patient's presented seizure officially reported by radiologist. A total of 9 candidate predictors were preselected. The prediction model was developed using a full multivariable logistic regression with backward stepwise elimination. We evaluated the model's predictive performance in terms of its discriminative ability and calibration via AuROC and calibration plot. The application was then constructed based on final model. A total of 362 patients were included into the analysis which comprising of 71 patients with positive CT head findings and 291 patients with normal results. Six final predictors were identified including: Glasgow coma scale, the presence of focal neurological deficit, history of malignancy, history of CVA, Epilepsy, and the presence of alcohol withdrawal symptom. In terms of discriminative ability, the final model demonstrated excellent performance (AuROC of 0.82 (95% CI: 0.76-0.87)). The calibration plot illustrated a good agreement between observed and predicted risks. This prediction model offers a reliable tool for effectively reduce unnecessary use and instill confidence in supporting physicians in determining the need for CT head scans in non-traumatic patients with seizures.

Biobehavioral approach to distinguishing panic symptoms from medical illness

Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.

Excessive Use of Benzodiazepines Is a Risk Factor for Endotracheal Intubation in Children Who Present to Emergency With Prehospital Status Epilepticus

OBJECTIVES

There is lack of evidence-based information on the use and timing of endotracheal intubation (ETI) in children with prehospital status epilepticus (SE).

METHODS

The aim of this study was to investigate ETI use, timing, risk factors, and outcomes in children presenting to a single-center children's emergency (CE) with prehospital SE, over a 5-year period.

RESULTS

A total of 118 events involving children presenting to CE with ongoing prehospital SE were included, and 39% (46/118) of the events required ETI. The most common indication for ETI was respiratory depression. The median time to intubation after arrival at CE was 20.0 minutes (1-155 minutes). Risk factors associated with ETI use include the administration of more than 2 benzodiazepines (26.1% vs 4.2%, P < 0.001) and the use of second- or third-line antiepileptic therapy ( P < 0.001). The use of more than 2 doses of benzodiazepines was found in 12.7% (15/118) of the patients. In patients who received excessive benzodiazepines, 87% (13/15) of them required intubation.

CONCLUSIONS

Excessive use of benzodiazepine was found to be a main risk factor for ETI in patients with prehospital SE. Avoidance of the excessive use of benzodiazepines and adhering to clinical management guidelines may reduce the risk for ETI in the CE. The best approach to airway management in children with prehospital SE is lacking and urgently needed.

Levothyroxine Treatment Among Pregnant Women and Risk of Seizure in Children: A Population-Based Cohort Study

INTRODUCTION AND OBJECTIVE

The risk of seizure in offspring following prenatal exposure to levothyroxine is not well investigated. This study aimed to evaluate the association between levothyroxine treatment among pregnant women and the risk of seizure in their offspring.

METHODS

This population-based cohort study included all pregnant women who delivered a live birth between January 2001 to January 2018, with a follow-up to December 2020, using data from the Hong Kong Clinical Data Analysis and Reporting System. Propensity score fine-stratification weighted hazard ratios (wHR) with 95% confidence intervals (CIs) were presented to assess the association between maternal levothyroxine use during pregnancy and seizures in children.

RESULTS

Among 528,343 included mother-child pairs, 3044 children were prenatally exposed to levothyroxine at any time during the pregnancy period. A significantly increased risk of seizure was observed in children of the prenatally exposed group compared with the prenatally unexposed group (wHR 1.12, 95% CI 1.02-1.22). An increased risk of seizure was observed when comparing the prenatally exposed group with euthyroid mothers who had no history of thyroid-related diagnosis or prescriptions (wHR 1.12, 95% CI 1.02-1.23). However, no significant difference was observed between the prenatally exposed group and those previously exposed to levothyroxine but had stopped during pregnancy (wHR 0.97, 95% CI 0.66-1.44). No significant difference was observed in the sibling-matched analysis either (wHR 1.23, 95% CI 0.76-2.01).

CONCLUSION

The observed increased risk of seizure in children born from mothers exposed to levothyroxine during pregnancy might be due to residual confounding by maternal thyroid disease. The findings support the current guidelines on the safe use of levothyroxine treatment during pregnancy.

Pathology testing in non-trauma patients presenting to the emergency department with recurrent seizures

OBJECTIVE

Excessive pathology testing is associated with ED congestion, increased healthcare costs and adverse patient health outcomes. This study aimed to determine the frequency, yield and influence of pathology tests among patients presenting to the ED with atraumatic recurrent seizures.

METHODS

This was a retrospective cohort study conducted at a level 4 adult ED in Australia and included atraumatic patients presenting to ED with recurrent seizures over a 4-year period (2017-2020). The primary outcome was the frequency of pathology tests. Additionally, the proportion of abnormal pathology test results and the association between pathology tests and change in management were assessed.

RESULTS

Of the 398 eligible presentations, 346 (86.9%, 95% confidence interval [CI] 83.3-89.9%) underwent at least one pathology test. In total 18.3% (n = 517) of pathology tests had an abnormal result which led to 15 changes in ED management among 12 presentations. Patients who had an abnormal pathology test result were more likely to undergo a change in antiepileptic drug management (odds ratio 2.08, 95% CI 1.23-3.65; P = 0.008).

CONCLUSION

Most patients presenting to the ED with atraumatic recurrent seizures underwent pathology tests. Abnormalities were frequently detected but were uncommonly associated with change in management. Abnormal pathology test results were associated with changes in antiepileptic drug management although rarely led to acute changes in patient management. This study suggests that pathology tests may be excessively requested in this population.

Seizure Analysis Presented to Emergency Department in Saudi Arabia: New VS Chronic Cases

Background

Epilepsy, characterized by recurrent unprovoked seizures, poses a significant global burden on individuals and healthcare systems. Accurate identification of underlying causes is vital for optimal intervention. However, studies reveal a lack of standardized approaches, potentially resulting in unnecessary investigations.

Objective

We aimed to highlight the importance of avoiding unnecessary testing to minimize healthcare costs and resource waste.

Methods

In the Emergency Department of King Fahd Hospital of the University (KFUH) in Alkhobar, a retrospective cross-sectional study encompassed 190 patients presenting with seizures from January 1, 2020, to December 31, 2022. The study aimed to elucidate the epidemiological profile and distinguish clinical and demographic factors between new onset seizures and known cases.

Results

The study included 190 epilepsy cases, with 51.1% known and 48.9% new onset. Generalized tonic-clonic seizures were prominent (43.2%), and non-compliance (24.2%) was a leading cause. New onset seizures were associated with abnormal CT findings (p=0.025), drug use (74.2%), and intoxication (6.5%). Demographically, Saudis showed higher new onset prevalence (82.8%, p=0.001).

Conclusion

The average length of stay was 5.93 hours, and the distribution of new vs. known cases was nearly equal among the 190 patients. Laboratory findings showed no significant associations with either group, mostly falling within the normal range. To optimize care further, we recommend continued refinement of protocols, emphasis on medication compliance.

Teaching distinguishing semiological features improves diagnostic accuracy of seizure-like events by emergency physicians

Background

Misdiagnosis of seizure-like events (SLE) in emergency situations is common. Here, we evaluate whether a single, video-based lesson highlighting distinguishing semiological features can improve the diagnostic accuracy of emergency physicians for epileptic seizures (ES), psychogenic non-epileptic seizures (PNES) and syncopes (SY).

Methods

40 emergency physicians (24 anesthetists, nine surgeons and seven internal medicine specialists by primary specialty) participated in a prospective trial on the diagnostic accuracy of SLE. They assessed video-displayed SLE at two time points: before and after a lecture on distinguishing semiological features. In the lecture, semiological features were demonstrated using patient videos, some were acted by the instructor in addition. The increase in correct diagnoses and recognition of distinguishing semiological features were analyzed.

Results

Before the lesson, 45% of 200 SLE-ratings were correct: 15% of SY (n = 40), 30% of PNES (n = 40), 59% of ES (n = 120, focal to bilateral tonic–clonic seizures (FBTCS) 87.5% (n = 40), focal impaired aware seizures (FIAS) 45% (n = 80)). Semiology teaching increased both the rate of correct diagnoses of SLE to overall 79% (p < 0.001) (ES 91% (p < 0.001), FBCTS 98% (n.s.), FIAS 88% (p < 0.001), PNES 88% (p < 0.001), SY 35% (p < 0.001)), and the number of recognized distinguishing semiological features. We identified several semiological features with high entity specific positive predictive values (> 0.8).

Conclusions

A single 45-min video-based lesson highlighting distinguishing semiological features improves the diagnostic accuracy of ES, PNES and SY by emergency physicians. We expect that including this aspect into the curriculum of emergency physicians will lead to better individual patient treatment in pre-hospital medicine and more appropriate subsequent use of clinical resources.

Risk of Epilepsy in Children Presenting to Emergency Departments with Their First Afebrile Seizure: A Retrospective Multicenter Study

Seizure is one of the most common neurologic disorders in pediatric emergency department visits. Early detection of epilepsy development in children with afebrile seizures is important. We identified predictors of epilepsy development in children with their first afebrile seizure. In this retrospective multicenter study, we enrolled pediatric patients aged 1 month to 18 years who presented with afebrile seizures at the emergency department from January 2017 to December 2020. Multivariable logistic regression analysis was performed to identify factors associated with epilepsy development. A total of 417 pediatric patients were enrolled, 161 (38.6%) of whom developed epilepsy. From the multivariable logistic regression analysis, older age at onset (2−5 years, odds ratio [OR] 2.611, p = 0.010; 11−15 years, OR 3.138, p = 0.003; 16−18 years, OR 4.292, p = 0.002), longer seizure duration of more than 10 min (OR 4.869, p = 0.006), two or more seizures (OR 2.378, p = 0.004), lethargy (OR 2.341, p = 0.021), and a lactate level > 2.27 mg/dL (OR 4.205, p < 0.001) were significant predictors for the development of epilepsy in children experiencing their first afebrile seizure.

Race and the emergency department management of febrile seizures

To determine if racial disparities exist in the management of febrile seizures in a large pediatric emergency department (ED), We performed a retrospective cross-sectional analysis of children 6 months to 6 years-old who presented to the ED with a febrile seizure over a 4-year period. Multivariate logistic regression models were built to examine the association between race and the primary outcome of neuroimaging, and secondary outcomes of hospital admission and abortive anticonvulsant prescription at ED discharge. There were 980 ED visits during the study period. Overall, 4.0% of children underwent neuroimaging and 11.1% were admitted. Of the 871 children discharged from the ED, 9.4% were prescribed an abortive anticonvulsant. There were no differences by race in neuroimaging or hospital admission. However, black children were less likely to be prescribed abortive anticonvulsants (adjusted odds ratio [aOR] 0.47; 95% confidence interval [CI]: 0.23-0.96) compared to non-black peers, when adjusting for demographic and clinical confounders. Stratification by insurance revealed that this disparity existed in Medicaid-insured patients (aOR 0.33, 95% CI: 0.14-0.78) but not in privately-insured patients. We found no racial disparities in neuroimaging or hospital admission among ED patients with febrile seizures. We did find racial disparities in our secondary outcome of abortive anticonvulsant prescription, driven primarily by individuals on Medicaid insurance. This pattern of findings may reflect the lack of standardized recommendations regarding anticonvulsant prescription, in contrast to the guidelines issued for other ED management decisions. Further investigation into the potential for treatment guidelines to reduce racial disparities is needed.

Diagnostic testing in nontrauma patients presenting to the emergency department with recurrent seizures: A systematic review

BACKGROUND

There is a lack of consensus regarding the role of investigations among patients presenting to the emergency department (ED) with recurrent seizures. The aim of this systematic review was to determine the frequency and utility of commonly requested investigations for nontrauma patients presenting to the ED with recurrent seizures.

METHODS

The MEDLINE, EMBASE, and Cochrane Library databases were searched (March 2021) for articles on this topic using search terms related to recurrent seizures, investigations, and the ED. The inclusion criteria required that articles include adult nontrauma patients presenting to the ED. Studies exclusively investigating first-episode seizures, trauma patients, and status epilepticus were excluded. Eligible studies were assessed for bias using the Newcastle-Ottawa scale. Results of studies were presented using proportions.

RESULTS

There were six cohort studies included that contributed data from 36,595 patients. All six studies assessed at least one of our primary outcomes for computed tomography (CT) brain scans. The proportion of patients who underwent a head CT ranged from 13% to 42%. The rates of abnormal head CT findings ranged from 8% to 21%. One study reported on magnetic resonance imaging (MRI) and found it used infrequently in 0.79% of cases. The proportion and yield of nonneuroimaging investigations were not well evaluated in this patient population. Only one study reported on the utility of sodium levels or blood glucose results for this population and reported abnormalities in sodium levels for 19% of patients and abnormalities in glucose levels in 50% of patients.

CONCLUSIONS

In this population, CT brain scans appeared to be performed uncommonly but with moderate rates of abnormal findings. In the absence of prolonged alteration of consciousness, a history of brain tumor, or positive neurologic findings, however, neuroimaging was of low yield. Given the heterogeneity and potential limitations of these studies, further research on this topic is required.

Care in Europe after presenting to the emergency department with a seizure; Position paper and insights from the European Audit of Seizure Management in Hospitals (EuroNASH)

BACKGROUND

This position paper makes recommendations following an audit of care provided to people presenting with a seizure to Emergency Departments (ED) in Europe.

METHODS

Participating countries were asked to include 5 hospitals agreeing to identify 50 consecutive seizure patients presenting to their ED between 1 August 2016 and 31 August 2017. Anonymous data were collected to web database. Where quoted, percentages are mean site values and ranges are 10^th to 90^th centile.

RESULTS

Data were collected on 2204 ED visits (47 sites, up to 6 per country, across 15 countries): 1270 (58%) known epilepsy, 299 (14%) previous blackouts but no epilepsy diagnosis, 634 (29%) with a first seizure. Wide variability was identified for most variables. Of those with known epilepsy, 41.2% (range 26.2% to 59.6%) attended ED in the previous 12 months, but only 64.7% (range 37.2% to 79.8%) had seen an epilepsy specialist in the previous 12 months. 67.7% (range 34.0% to 100%) were admitted; 53.1% to a neurology ward (range 0.0% to 88.9%). Only 37.5% first seizure patients (range 0.0% to 71.4%) were given advice about driving.

CONCLUSIONS

and recommendations We recommend that in Europe we: Agree guidance on the management and onward referral of those presenting to the ED with a seizure. Create a referral process that can be easily implemented. Ensure that the seizure services receive referrals and see the patients within a short time period. Develop and implement a simple system to allow continuous monitoring of key indices of epilepsy care.

Factors Predicting the Frequency of Second Seizures in Patients Presenting to the Emergency Department With Seizures: A Prospective Observational Study

Introduction

This study aimed to determine the factors that trigger seizures in patients reporting to our emergency department (ED) with seizures and the factors that affect recurrent seizures during the emergency department stay.

Materials and methods

This study was designed prospectively and was conducted among patients over the age of 18 years who reported to the ED of the Education and Research Hospital with complaints of epileptic seizure between July 01, 2020 and July 01, 2021. In addition to the sociodemographic information of the patients, the time of admission after the seizure, the medications used, comorbidities, the treatment given in the ED, history of trauma, previous epilepsy diagnosis, time of last seizure, alcohol use in the last 24 hours, insomnia, presence of infective symptoms in the past week, vital parameters, blood tests, and presence of recurrent seizure during hospital follow-up were recorded.

Results

The median age of the 102 patients included in the statistical analysis was 37 (25%-57%), and 61 (59.8%) were men. Patients who came to the ED with the complaint of seizures were divided into two groups, namely, those who had recurrent seizures and those who did not. When the differences between the groups in terms of various variables were examined, no statistically significant difference was found in the univariate analysis, except for WBC, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) values. The diagnostic value of WBC, AST, and ALT levels in predicting recurrent seizures in emergency follow-up was analyzed using a receiver operating characteristic curve.

Conclusion

In this study, we could not find a parameter that can predict the probability of recurrent seizures in the ED in patients presenting with epileptic seizures.

Association between benzodiazepine outpatient treatment and risk of early seizure recurrence in emergency patients with seizure: A multicenter retrospective study

INTRODUCTION

Seizures are one of the most common neurological reasons for emergency department (ED) visits. The benefit of ED-initiated, short-course outpatient benzodiazepine (BZD) treatment to prevent early recurrent seizure is unknown. This study assesses the risk of early seizure recurrence in patients who were or were not started with outpatient BZD in the ED.

METHODS

This was a multicenter retrospective study conducted in eight French EDs between January 1 and December 31, 2019. All patients admitted for seizure were retrospectively screened and those discharged home from the ED were included. Patients with a history of chronic alcohol intoxication or chronic BZD therapy were excluded. Baseline characteristics, type of seizure, and 30-day outcome were retrospectively collected from the electronic health records. The primary endpoint was a return visit for seizure recurrence within 30 days. Independent factors associated with a seizure recurrence were identified using a multivariable binary logistic regression.

RESULTS

A total of 2,218 patients were included and 1,820 were analyzed. The median age was 39 years and 60% were men. Among them 82% of patients had a generalized tonic-clonic seizure and 47% of seizures were idiopathic. BZD treatment was started in 773 (42%) patients. A total of 154 (8%) patients had an early recurrence at 30 days: 68 (9%) in patients who were treated with BZD versus 86 (8%) in patients who were not (odds ratio [OR] = 1.07, 95% confidence interval [CI] = 0.71 to 1.43). In multivariable analysis, two factors were independently associated with the primary endpoint: chronic epileptic treatment (adjusted OR = 2.58, 95% CI = 1.55 to 4.37) and having had a focal seizure (adjusted OR = 2.16, 95% CI = 1.56 to 4.37).

CONCLUSION

BZD therapy was started in 42% of patients who were discharged home after ED visit for a seizure. This treatment was not an independent factor associated with the risk of return visit for seizure recurrence at 30 days.

New-onset seizures in adults: Low diagnostic yield of gadolinium contrast in initial brain MRI evaluation

BACKGROUND AND PURPOSE

The diagnostic utility of contrast MR-imaging in adult new-onset seizures without clinically suspected neoplasia or infection is not well defined in the literature. Imaging guidelines consider both contrast and noncontrast MR-imaging examinations appropriate in this clinical scenario. The purpose of this study was to evaluate the utility of contrast MR-sequences in evaluation of seizure in patients without suspicion for neoplasia or infection.

METHODS

Imaging and clinical data were reviewed for 103 consecutive patients admitted for phase-1 seizure monitoring with the following criteria: (1) MRI-brain performed with/without intravenous contrast; (2) no clinical suspicion for central nervous system (CNS) infection; and (3) no history of CNS neoplasia, or suspected metastatic disease. Readers designated cases as lesional or nonlesional. Lesional cases were further categorized as either visualized on noncontrast sequences only, contrast sequences only, or both.

RESULTS

29/103 (28%) patients had epileptogenic lesions, 74/103 (72%) were nonlesional studies. 29/29 (100%) lesional abnormalities were detected on noncontrast sequences (sensitivity 100% [95 confidence interval (CI): 88-100], specificity 100% [95 CI: 95-100]). 23/29 (79.3%) lesional cases were visualized on both noncontrast and postcontrast sequences. 6/29 (20.7%) were visualized only on noncontrast sequences. No lesional cases were detected exclusively on postcontrast MR sequences. With an observed nonlesional extraneous contrast MR-imaging rate of 72%, estimated excess cost of contrast MR-imaging per 1000 patients using Medicare data was $103,680 USD.

CONCLUSIONS

Contrast MR-imaging has limited diagnostic utility in initial screening of adult new-onset seizure patients without clinically suspected neoplasia or infection. More judicious use of contrast MR-imaging in this patient population may reduce unnecessary exposure to gadolinium and lower associated healthcare costs.

Use of Neuroimaging for Children With Seizure in General and Pediatric Emergency Departments

BACKGROUND

Seizure is a common reason for children to visit the emergency department (ED). Pediatric and general EDs may obtain computed tomography (CT) scans of the head for seizure at different rates.

OBJECTIVE

To compare rates of head CT for pediatric seizure between general and pediatric EDs.

METHODS

This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey for patients <21 years of age presenting to an ED with a chief complaint or diagnosis of seizure between 2006 to 2017. Of these patients, we compared head CT use between general and pediatric EDs among patients with fever, trauma, and co-diagnosis of epilepsy using univariable risk differences and in a multivariable logistic regression model.

RESULTS

More than 5 (5.4) million (78.8%) and 1.5 million (21.2%) pediatric patients with seizure presented to general and pediatric EDs, respectively. Of those, 22.4% (1.21 million) and 13.2% (192,357) underwent CT scans of the head, respectively, a risk difference of 9.2% (95% confidence interval [CI] 2.3-16.1). General EDs obtained CT scans of the head more often in patients with epilepsy (risk difference 17.9% [95% CI 4.0-31.9]), without fever (12.2% [95% CI 3.1-21.4]), and without trauma (10.6% [95% CI 4.4-16.8]). Presenting to a general ED, being afebrile, or having trauma were associated with head CT with adjusted odds ratios of 1.7 (95% CI 1.0-3.2), 4.9 (95% CI 2.6-9.2), and 2.0 (95% CI 1.2-3.4), respectively. Age, gender, and epilepsy were not associated with head CT among all patients with seizure.

CONCLUSIONS

Children with seizure are more likely to undergo CT scans of the head at general EDs compared with pediatric EDs.

Quantitative Infrared Pupillometry in Nonconvulsive Status Epilepticus

BACKGROUND

Nonconvulsive status epilepticus (NCSE) is a frequent disorder in neurocritical care and diagnosing it can be challenging. NCSE patients often show altered pupil function, but nature and extent may vary. Infrared pupillometry allows detection of subtle changes of pupil function. The neurological pupil index (NPi) is considered a surrogate marker of global pupil function which is supposed to be independent of absolute parameters such as the pupil diameter.

OBJECTIVE

Cross-sectional observational study to assess whether NPi is altered in NCSE.

METHODS

128 consecutive adult emergency patients who had experienced a suspected seizure, have not reached their prior functional level regarding level of consciousness, mental status or focal deficits, had no obvious clinical signs of status epilepticus and had an EEG indication as determined by the treating clinician for exclusion of NCSE were examined by routine EEG and pupillometry. Exclusion criteria were ocular comorbidity (n = 21) and poor EEG quality (n = 4). Pupillometry was performed once directly before the beginning of EEG recording. NCSE diagnosis (no NCSE, possible NCSE and confirmed NCSE) was established according to Salzburg consensus criteria blinded to pupillometry results. Group comparison was performed for right NPi, left NPi, lowest NPi of both sides (minNPi) and the absolute difference of both sides (diffNPi) applying non-parametric testing. In post-hoc analysis, receiver operating characteristics (ROC) of NCSE diagnosis (combined confirmed NCSE and possible NCSE) were performed for minNPi and diffNPi.

RESULTS

From 103 patients included in the final analysis, 5 (4.9%) had confirmed NCSE, 7 (6.8%) had possible NCSE. Right NPi (p = 0.002), left NPi (p < 0.001) and minNPi (p < 0.001) were significantly lower in "confirmed NCSE" and "possible NCSE" compared to "no NCSE"; diffNPi was significantly higher in "confirmed NCSE" and "possible NCSE" compared to "no NCSE" (p < 0.001). There was no significant difference of minNPi and diffNPi between "confirmed NCSE" and "possible NCSE". ROC analysis showed an optimal cut-off of minNPi for NCSE diagnosis of 4.0 (AUC = 0.93, 95% CI 0.86-0.99). Optimal ROC analysis cut-off of diffNPi for NCSE diagnosis was 0.2 (AUC = 0.89, 95% CI 0.80-0.99).

CONCLUSIONS

NPi was significantly reduced and the difference between left and right NPi was significantly higher in confirmed NCSE. An NPi < 4.0 on either side as well as an NPi difference of both sides > 0.2 may be potential indicators of NCSE. Infrared pupillometry may be a helpful diagnostic tool in the assessment of NCSE and should be studied further in larger populations.

SARS-CoV-2 pandemic and epilepsy: The impact on emergency department attendances for seizures

INTRODUCTION

The risk of acquiring SARS-CoV-2 in a hospital setting and the need of reorganizing the Emergency Departments (EDs) to cope with infected patients have led to a reduction of ED attendances for non-infectious acute conditions and to a different management of chronic disorders.

METHODS

We performed a retrospective study evaluating the frequency and features of ED attendances for seizures during the lockdown period (March 10th-April 30th 2020) in the University Hospital of Trieste, Italy. We studied the possible pandemic impact on the way patients with seizures sought for medical assistance by comparing the lockdown period to a matched period in 2019 and to a period of identical length preceding the lockdown (January 18th-March 9th 2020).

RESULTS

A striking decrease in total ED attendances was observed during lockdown (4664) compared to the matched control (10424) and to the pre-lockdown (9522) periods. A similar reduction, although to a lesser extent, was detected for seizure attendances to the ED: there were 37 during lockdown and 63 and 44 respectively during the two other periods. Intriguingly, during the lockdown a higher number of patients attended the ED with first seizures (p = 0.013), and more EEGs (p = 0.008) and CT brain scans (p = 0.018) were performed; there was a trend towards more frequent transport to the ED by ambulance (p = 0.061) in the lockdown period.

CONCLUSIONS

Our data suggest that the pandemic has affected the way patients with seizures access the Health Care System.

Hypophosphatemia compared to classical biomarkers of tonic clonic seizures

BACKGROUND

Hypophosphatemia was recently reported as a potential marker of tonic-clonic (TC) seizures among patients with transitory loss of consciousness (TLOC). Its value compared to classical markers (creatine kinase [CK] and lactate) is however unknown.

AIM

Compare the diagnostic performance of hypophosphatemia, plasma CK, and lactate levels for distinguishing TC seizures from other TLOCs, alone or in combination.

METHODS

128 patients aged 18-90, consecutively admitted to our hospital emergency department for TLOC were included. Diagnostic accuracy of plasma phosphate, CK, and lactate levels were compared with ROC curves.

RESULTS

We found significantly higher CK (median 154 U/l, range 38-5608; vs 115.5, 37-2340 U/l; p = 0.037) and lower phosphatemia (median 0.79 mmol/l, 0.34-1.37; vs 0.93, 0.52-1.89 mmol/l, p = 0.007) in TC seizures compared to other TLOCs; lactatemia was not different, although using a smaller sample (n = 72). Hypophosphatemia was the only independent predictor of TC seizures, even in later samples (>2 h). Comparing ROC curves, Combining hypophosphatemia and hyperCKemia had higher diagnostic accuracy for TC seizures than hyper-CKemia alone (AUC 0.68, 95 % CI 0.571-0.783 vs. 0.59, 95 % CI 0.475-0.706; p = 0.018), but the combination was only marginally better than hypophosphatemia alone (AUC 0.67, 95 % CI 0.559-0.778).

CONCLUSION

Hypophosphatemia seems to be more useful than CK levels for diagnosing TC seizures in patients assessed in an emergency setting for TLOC. Combining both parameters together does not significantly increase the diagnostic yield. No conclusion could be drawn regarding the comparison with lactate. A prospective study is needed.

Etiological Profile of Afebrile Seizures in Infants in a Tertiary Care Center from southern India

Introduction

Seizure is the most common neurological illness in pediatric population and its risk is highest in the first year of life. Studies regarding etiology of afebrile seizures worldwide and in India are limited; hence, the current study was undertaken.

Objective

The objective of this work was to study the etiology of afebrile seizures in infants aged 1 month to 1 year.

Materials and Methods

A retrospective study of afebrile infantile seizure was conducted at pediatric neurology outpatient department between January 2015 and September 2017. All children with first episode of afebrile seizures were included. Biochemical and hematological investigations, imaging, and electroencephalogram were performed whenever necessary. Simple descriptive statistics were used to analyze the data in the form of frequencies with percentages and median as applicable.

Results

One hundred twenty-one children with a mean age of 8.1 months were analyzed. Of these children, 58% were males. Positive family history was found in 1.65% children, developmental delay in 70%, and dysmorphism in 8%. Presenting seizure type were generalized (74%), focal (21%), and unknown (6%) onset. Etiology was deducible in 92% cases. Structural etiology was the most common (66%), followed by metabolic (12%), infections (7%), and others (6%). In structural pathology, common causes were perinatal insult (38%) and cerebral malformations (18%). Imaging was done in 98 cases and yield was 83% (85 cases).

Conclusion

Etiology was deducible in 92% of children. Seizures due to structural etiology, secondary to perinatal insult followed by metabolic and infections, are important causes. Imaging aids are important in etiological diagnosis. Etiological evaluation should be considered in children following first episode of afebrile seizures, especially in developing countries like India.

Fits, faints, falls and funny turns: cost and capacity savings in Queensland from the accelerated transient attack pathway initiative (ATAP)

BACKGROUND

falls, seizures, syncope and transient ischaemic attacks (TIA) are common presentations to emergency departments sharing overlapping clinical features and diagnostic uncertainties. These transient attacks can be markers of serious adverse outcomes and are associated with high admission rates. We evaluated the effects of an integrated suite of pathways for transient attacks designed to improve adherence to best practices and reduce costs through fewer admissions.

METHODS

a suite of clinician-designed pathways based on initial presenting diagnosis was developed to support ambulant care in a large hospital in Queensland, Australia. We performed a set of regression analyses to identify the differences in total cost and length of stay (LOS) before and after implementation. We conducted a Monte Carlo simulation to estimate the cost savings of the freed capacity in the patient cohort.

RESULTS

pathway implementation was associated with reduced admitted LOS and costs. Falls patients admitted LOS declined by 32.5%, and admission costs by 19.5%. Syncope, seizure, and TIA patients admitted LOS declined by 22% with no change in admitted costs. Despite a small increase in 90-day representations, total emergency department LOS was unchanged. Emergency department costs were similar between falls and non-falls patients. The Monte Carlo analysis showed that the most likely outcome was a cost savings in freed capacity of $71 per patient episode.

CONCLUSION

the ATAP suite of pathways was associated with reduction in LOS, release of capacity and reduction in costs. Further study is needed to evaluate mechanisms and clinical outcomes in this vulnerable population.

Variability with Astroglial Glutamate Transport Genetics Is Associated with Increased Risk for Post-Traumatic Seizures

Excitotoxicity contributes to epileptogenesis after severe traumatic brain injury (sTBI). Demographic and clinical risk factors for post-traumatic seizures (PTS) have been identified, but genetic risk remains largely unknown. Thus, we investigated whether genetic variation in astroglial glutamate transporter genes is associated with accelerated epileptogenesis and PTS risk after sTBI. Adults (n = 267) 18-75 years old were assessed over a three-year period post-TBI. Single nucleotide polymorphisms (SNPs) throughout the SLC1A2 and SLC1A3 genes were assayed. Kaplan-Meier estimates and log-rank statistics were used to compare seizure frequencies by genotype. Multivariate Cox proportional hazards regression was used to estimate hazard ratios (HRs) for genotypes significant in Kaplan-Meier analyses. Thirty-nine tagging SNPs were examined (SLC1A2: n = 21, SLC1A3: n = 18). PTS developed in 57 (21.4%) individuals. Of those with PTS, n = 20 (35.7%) had an immediate/early seizure within the first seven days, and n = 36 (64.3%) had a late seizure occurring between eight days and three years post-TBI. When adjusting for multiple comparisons, rs4869682 genotypes (SLC1A3, GG vs. T-carriers) were associated with time to first seizure (p = 0.003). Median time until first seizure was 20.4 days for individuals with a GG genotype and 44.8 days for T-carriers. After adjusting for covariates, rs4869682 GG-homozygotes had a 2.05 times increased PTS risk versus T-carriers (aHR = 2.08, 95% confidence interval: 1.20, 3.62, p = 0.009). Variation within SLC1A3 is associated with accelerated epileptogenesis and clinical PTS development after sTBI. Future studies should validate these findings and examine how genetic variation at rs4869682 may be a target for PTS prevention and treatment.

Cost-Effectiveness of Evaluation of Children With Epilepsy in the Emergency Department: Need for Investment in Patient Education

We aimed to study cost-effectiveness of seizure evaluation of children with epilepsy in the emergency department (ED). We reviewed epilepsy patients seen at our ED for 1 year. Age, laboratory and neuroimaging results, treatment, disposition, and usefulness of the visit (need for hospitalization, clinical improvement) were analyzed. We identified 330 patients, aged 23 days-21 years, 190 (57.5%) had blood tests, 45 (13.6%) urinalysis, 2 (0.6%) cerebrospinal fluid testing, and 44 neuroimaging studies (13.3%). Tests' positive yield were 41%, 11%, 0%, and 4.5%, respectively. One-third of patients (n = 122) were treated with antiepileptic drugs. Other treatments were administered to 44 (13.3%). One hundred eighteen patients (35.7%) were admitted to our hospital, 208 (63%) discharged to home. Two hundred eight visits were useful (63%). One-third of visits did not provide useful patient care. Their visits were expensive and not very cost-effective. Investment in patient education could decrease unnecessary ED visits.

Laboratory markers of cardiac and metabolic complications after generalized tonic-clonic seizures

Background

Generalized tonic-clonic seizures (GTCS) frequently lead to emergency inpatient referrals. Laboratory blood values are routinely performed on admission to detect underlying causes and metabolic or cardiac complications. Our goal was to assess the nature and frequency of complications occurring in association with GTCS.

Methods

We retrospectively extracted data from emergency protocols and discharge letters of adult patients admitted to the Department of Epileptology between 01/2010 and 06/2015. Inclusion criteria were diagnosis of GTCS and admission via emergency services. Exclusion criteria were status epilepticus prior to admission to hospital and non-generalized seizures.

Results

A total of 223 patients (of 986 screened cases) were included. Overall, 1.8% required intubation while 1.3% had less severe respiratory problems. In 5.6% of patients, a transient hypoxemia was measured. Hypertensive urgencies affected 7.8% of the patients, sinus tachycardia occurred in 41.2%. Troponin I (cTNI) was determined in 75 patients and was increased in 12% of these cases. Occurrence of elevated cTNI levels was significantly correlated with patient’s age. Four patients were diagnosed with NSTEMI and one patient with STEMI. Creatine kinase (CK) was increased in 59.4% of the patients, with <5-fold increases in 47%, <10-fold in 5.8% and >10-fold increases in 4.3%. Rhabdomyolysis with an >50 fold increase in CK was detected in 1.9% of patients. Prolonged disturbances of consciousness affected 5% of cases while agitation, delirium, and psychotic episodes occurred in 6.3%. Minor traumatic injuries affected 45.7% of patients.

Conclusions

Troponin elevations in association with GTCS are one of the more common complications after emergency admissions especially in older patients. In our selected patient population, serious complications such as intracranial hemorrhage, myocardial infarction and acute renal failure occurred in <1% of GTCS only.

Safety Threats During the Care of Infants with Hypoglycemic Seizures in the Emergency Department: A Multicenter, Simulation-Based Prospective Cohort Study

BACKGROUND

Errors in the timely diagnosis and treatment of infants with hypoglycemic seizures can lead to significant patient harm. It is challenging to precisely measure medical errors that occur during high-stakes/low-frequency events. Simulation can be used to assess risk and identify errors.

OBJECTIVE

We hypothesized that general emergency departments (GEDs) would have higher rates of deviations from best practices (errors) compared to pediatric emergency departments (PEDs) when managing an infant with hypoglycemic seizures.

METHODS

This multicenter simulation-based prospective cohort study was conducted in GEDs and PEDs. In situ simulation was used to measure deviations from best practices during management of an infant with hypoglycemic seizures by inter-professional teams. Seven variables were measured: five nonpharmacologic (i.e., delays in airway assessment, checking dextrose, starting infusion, verbalizing disposition) and two pharmacologic (incorrect dextrose dose and incorrect dextrose concentration). The primary aim was to describe and compare the frequency and types of errors between GEDs and PEDs.

RESULTS

Fifty-eight teams from 30 hospitals (22 GEDs, 8 PEDs) were enrolled. Pharmacologic errors occurred more often in GEDs compared to PEDs (p = 0.043), while nonpharmacologic errors were uncommon in both groups. Errors more frequent in GEDs related to incorrect dextrose concentration (60% vs. 88%; p = 0.025), incorrect dose (20% vs. 56%; p = 0.033), and failure to start maintenance dextrose (33% vs. 65%; p = 0.040).

CONCLUSIONS

During the simulated care of an infant with hypoglycemic seizures, errors were more frequent in GEDs compared to PEDs. Decreasing annual pediatric patient volume was the best predictor of errors on regression analysis.

Clinicodemographic Profile of Children with Seizures in a Tertiary Care Hospital: A Cross-Sectional Observational Study

Seizures are one of the common causes for hospital admissions in children with significant mortality and morbidity. This study was conducted to study the prevalence and clinicodemographic profile of children with seizures in a tertiary care hospital of western Nepal. This prospective cross-sectional study conducted over a period of 2 years included all admitted children (2 months-16 years) with seizures. Among 4962 admitted children, seizures were present in 3.4% (n = 168) of children, with male preponderance. 138 (82.1%) children had generalized tonic-clonic seizures (GTCS) and 30 (17.9%) children had partial seizures. GTCS were more common than partial seizures in both sexes (male = 82.7%; female = 81.2%) and age groups. There was no statistical significance in the distribution of seizures (GTCS and partial seizures) with sexes (P = 0.813) and age groups (P = 0.955). Mean ages of children having GTCS and partial seizures were 8.2 ± 4.6 years and 8.2 ± 4.2 years, respectively. Loss of consciousness (55.4%), fever (39.9%), vomiting (35.1%), and headache (16.1%) were common complaints in seizure patients. Significant number of GTCS cases had fever (P = 0.041) and neurocysticercosis (n = 72; 43%) was the most common etiology in seizure patients. Idiopathic epilepsy (38 (22.6%)), meningoencephalitis (26 (15.5%)), and febrile convulsions (14 (8.33%)) were other leading disorders in children with seizures.

Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence-based Recommendations

INTRODUCTION

We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of adult and pediatric patients with a seizure and to compare these recommendations against the current protocol used by the 33 emergency medical services (EMS) agencies in California.

METHODS

We performed a review of the evidence in the prehospital treatment of patients with a seizure, and then compared the seizure protocols of each of the 33 EMS agencies for consistency with these recommendations. We analyzed the type and route of medication administered, number of additional rescue doses permitted, and requirements for glucose testing prior to medication. The treatment for eclampsia and seizures in pediatric patients were analyzed separately.

RESULTS

Protocols across EMS Agencies in California varied widely. We identified multiple drugs, dosages, routes of administration, re-dosing instructions, and requirement for blood glucose testing prior to medication delivery. Blood glucose testing prior to benzodiazepine administration is required by 61% (20/33) of agencies for adult patients and 76% (25/33) for pediatric patients. All agencies have protocols for giving intramuscular benzodiazepines and 76% (25/33) have protocols for intranasal benzodiazepines. Intramuscular midazolam dosages ranged from 2 to 10 mg per single adult dose, 2 to 8 mg per single pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intranasal midazolam dosages ranged from 2 to 10 mg per single adult or pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intravenous/intrasosseous midazolam dosages ranged from 1 to 6 mg per single adult dose, 1 to 5 mg per single pediatric dose, and 0.05 to 0.1 mg/kg as a weight-based dose. Eclampsia is specifically addressed by 85% (28/33) of agencies. Forty-two percent (14/33) have a protocol for administering magnesium sulfate, with intravenous dosages ranging from 2 to 6 mg, and 58% (19/33) allow benzodiazepines to be administered.

CONCLUSION

Protocols for a patient with a seizure, including eclampsia and febrile seizures, vary widely across California. These recommendations for the prehospital diagnosis and treatment of seizures may be useful for EMS medical directors tasked with creating and revising these protocols.

Pre-hospital midazolam for benzodiazepine-treated seizures before and after the Rapid Anticonvulsant Medication Prior to Arrival Trial: A national observational cohort study

BACKGROUND

Implementation of evidence-based treatment for pre-hospital status epilepticus can improve outcomes. We hypothesized that publication of a pivotal pre-hospital clinical trial (RAMPART), demonstrating superiority of intramuscular midazolam over intravenous lorazepam, altered the national utilization rates of midazolam for pre-hospital benzodiazepine-treated seizures, while upholding its safety and efficacy outside the trial setting.

METHODS AND FINDINGS

This is a retrospective, observational cohort study of pre-hospital patient encounters throughout the United States in the National Emergency Medicine Services Information System database, from January 2010 through December 2014. We compared the rates and odds of midazolam use as first-line treatment among all adult and pediatric benzodiazepine-treated seizures before and after RAMPART publication (February 2012). Secondary analyses were conducted for rates of airway interventions and rescue therapy, as proxies for safety and efficacy of seizure termination. 156,539 benzodiazepine-treated seizures were identified. Midazolam use increased from 26.1% in January 2010 to 61.7% in December 2014 (difference +35.6%, 95% CI, 32.7%-38.4%). The annual rate of midazolam adoption increased significantly from 5.9% per year to 8.9% per year after the publication of RAMPART (difference +3.0% per year; 95%CI, 1.6%-4.5% per year; adjusted OR 1.24; 95%CI, 1.17-1.32). Overall frequency of rescue therapy and airway interventions changed little after the publication of RAMPART.

CONCLUSIONS

These data are consistent with effective, ongoing, but incomplete clinical translation of the RAMPART results. The effects of the trial, however, cannot be isolated. The study was limited by broad inclusion of all benzodiazepine-treated seizures as well as a lack of information on route of drug of administration. The safety and effectiveness of midazolam for benzodiazepine-treated seizures in prehospital clinical practice appear consistent with trial data, which should encourage continuing increases in utilization.

Reduced Emergency Department Utilization by Patients With Epilepsy Using QI Methodology

BACKGROUND

Epilepsy or seizure care is the most common neurologic condition that presents to an emergency department (ED) and accounts for a large number of annual cases. Our aim was to decrease seizure-related ED visits from our baseline of 17 ED visits per month per 1000 patients to 13.6 ED visits per month per 1000 patients (20%) by July 2014.

METHODS

Our strategy was to develop a quality improvement (QI) project utilizing the Institute for Healthcare Improvement model. Our defined outcome was to decrease ED utilization for children with epilepsy. Rate of ED visits as well as unplanned hospitalizations for epilepsy patients and associated health care costs were determined. A QI team was developed for this project. Plan do study act cycles were used with adjustments made when needed.

RESULTS

Nineteen months after implementation of the interventions, ED visits were reduced by 28% (from 17 visits per month per 1000 patients to 12.2 per month per 1000 patients) during the past year. The average number of inpatient hospitalizations per month was reduced by 43% from 7 admissions per month per 1000 patients to 4 admissions per month per 1000 patients. For both outcome measures, a 2-sample Poisson rate exact test yielded a P value < .0001. Health care claims paid were less with $115 200 reduction for ED visits and $1 951 137 reduction for hospitalizations.

CONCLUSIONS

Applying QI methodology was highly effective in reducing ED utilization and unplanned hospitalizations for children with epilepsy at a free-standing children's hospital.

Polymorphisms of ABAT, SCN2A and ALDH5A1 may affect valproic acid responses in the treatment of epilepsy in Chinese

Aim: The clinical efficacy of valproic acid (VPA) varies greatly among epileptic patients. To find the potential genetic factors related to VPA responses, the pharmacogenetics study was conducted. Methods: Two hundred and one Chinese Han epileptic patients who were treated by VPA for at least 1 year were recruited. Up to 24 SNPs in 11 candidate genes that correlate with the metabolism, transport or target of VPA were genotyped. Results: Three SNPs, rs1731017 (ABAT), rs2304016 (SCN2A) and rs1054899 (ALDH5A1) were found associated with VPA responses with the p-values of 0.003, 0.007 and 0.048, respectively. Further interaction analysis showed that the interaction between rs17183814 (ABAT) and rs1641022 (SCN2A) was also correlated with the response of VPA (p = 0.006). Conclusion: This study found three SNPs and one interaction among ABAT, SCN2A and ALDH5A1 were significantly associated with VPA response, which indicated that these genes may play important roles in the pharmacological mechanism of VPA.

Synaptic Zn2+ and febrile seizure susceptibility

Zn²⁺ , the second most prevalent trace element in the body, is essential for supporting a wide range of biological functions. While the majority of Zn²⁺ in the brain is protein-bound, a significant proportion of free Zn²⁺ is found co-localized with glutamate in synaptic vesicles and is released in an activity-dependent manner. Clinical studies have shown Zn²⁺ levels are significantly lower in blood and cerebrospinal fluid of children that suffer febrile seizures. Likewise, investigations in multiple animal models demonstrate that low levels of brain Zn²⁺ increase seizure susceptibility. Recent work provides human genetic evidence that disruption of brain Zn²⁺ homeostasis at the level of the synapse is associated with increased seizure susceptibility. In this review, we have explored the clinical, functional and genetic data supporting the view that low synaptic Zn²⁺ increases cellular excitability and febrile seizure susceptibility. Finally, the review focuses on the potential of therapeutic Zn²⁺ supplementation for at risk patients.

Neuro-imaging evaluation after the first afebrile seizure in children: A retrospective observational study

PURPOSE

To evaluate the role of neuro-imaging in children presenting with the first afebrile seizure and determine factors that influence the outcome of imaging in a large paediatric emergency centre.

METHOD

This is a retrospective review of the medical records of all patients presenting with the first non-febrile seizure to a large paediatric emergency centre in the state of Qatar. Seizure classification followed the current ILAE classification system. Imaging was undertaken in our tertiary hospital and all images were reviewed by experienced neuro-radiologists. Student t test was used for statistical analysis.

RESULTS

Ninety-six children underwent neuro-imaging following the first afebrile seizure. Of them, thirty-two patients (33%) were reported to have abnormalities. Children below the age of two demonstrated a significantly higher percentage of abnormal imaging (59%); (p=0.002). Children presenting with prolonged seizures showed a high percentage of imaging abnormalities (58%); (p=0.003). Children with focal seizures demonstrated a higher percentage of imaging abnormality compared to those presenting with generalized seizures (35% vs 31%). This difference did not reach statistical significance.

CONCLUSION

Children below the age of two demonstrated significantly higher percentages of abnormal imaging (59%), as did children presenting with status epilepticus (58%). Neuro-imaging should be considered in infants and those with focal or prolonged seizures. Neuro-imaging informed decision making in 6-8% of children.

Structural and microstructral imaging of the brain in alcohol use disorders

Magnetic resonance imaging (MRI), by enabling rigorous in vivo study of the longitudinal, dynamic course of alcoholism through periods of drinking, sobriety, and relapse, has enabled characterization of the effects of chronic alcoholism on the brain in the human condition. Importantly, MRI has distinguished alcohol-related brain effects that are permanent versus those that are reversible with abstinence. In support of postmortem neuropathologic studies showing degeneration of white matter, MRI has shown a specific vulnerability of brain white matter to chronic alcohol exposure by demonstrating white-matter volume deficits, yet not leaving selective gray-matter structures unscathed. Diffusion tensor imaging (DTI), by permitting microstructural characterization of white matter, has extended MRI findings in alcoholics. This review focuses on MRI and DTI findings in common concomitants of alcoholism, including Wernicke's encephalopathy, Korsakoff's syndrome, hepatic encephalopathy, central pontine myelinolysis, alcoholic cerebellar degeneration, alcoholic dementia, and Marchiafava-Bignami disease as a framework for findings in so-called "uncomplicated alcoholism," and also covers findings in abstinence and relapse.

Utility of Obtaining a Serum Basic Metabolic Panel in the Setting of a First-Time Nonfebrile Seizure

New-onset nonfebrile seizures in an otherwise healthy child are common, affecting 25 000 to 40 000 U.S. children annually. We hypothesized seizure-provoking electrolyte disturbances such as hyponatremia, hypoglycemia, and hypocalcemia are uncommon in these children. From January 1, 2009 to May 31, 2009, 358 children aged 29 days to 18 years with a diagnosis code of 780.39 ("other convulsions" including "first time seizure," etc) were included for potential retrospective review. Children with known epilepsy and febrile seizures were excluded. Electrolytes were obtained in nearly all children with a history suggestive of an underlying abnormality (13 of 14, 93%) but also in half of children with a reassuring history (62 of 119, 52%). No child with an unremarkable history and exam was found to have electrolyte abnormalities falling below levels most likely to be associated with acute symptomatic seizures. Electrolytes are unlikely to be abnormal in an otherwise well-appearing child after a first-time nonfebrile seizure.

Loss of synaptic Zn2+ transporter function increases risk of febrile seizures

Febrile seizures (FS) are the most common seizure syndrome and are potentially a prelude to more severe epilepsy. Although zinc (Zn(2+)) metabolism has previously been implicated in FS, whether or not variation in proteins essential for Zn(2+) homeostasis contributes to susceptibility is unknown. Synaptic Zn(2+) is co-released with glutamate and modulates neuronal excitability. SLC30A3 encodes the zinc transporter 3 (ZNT3), which is primarily responsible for moving Zn(2+) into synaptic vesicles. Here we sequenced SLC30A3 and discovered a rare variant (c.892C > T; p.R298C) enriched in FS populations but absent in population-matched controls. Functional analysis revealed a significant loss-of-function of the mutated protein resulting from a trafficking deficit. Furthermore, mice null for ZnT3 were more sensitive than wild-type to hyperthermia-induced seizures that model FS. Together our data suggest that reduced synaptic Zn(2+) increases the risk of FS and more broadly support the idea that impaired synaptic Zn(2+) homeostasis can contribute to neuronal hyperexcitability.

Spatial patterns of epilepsy-related emergency department visits in california

Background

Socio-demographic factors are associated with increased emergency department (ED) use among patients with epilepsy. However, there has been limited spatial analysis of such visits.

Design and methods

California ED visit at the patient ZIP Code level were examined using Kulldorf’s spatial scan statistic to identify clusters of increased risk for epilepsy-related visits. Logistic regression was used to examine the relative importance of patient socio-demographics, Census-based and hospital measures.

Results

During 2009-2011 there were 29,715,009 ED visits at 330 hospitals, of which 139,235 (0.5%) had epilepsy (International Classification of Disease-9 345.xx) as the primary diagnosis. Three large urban clusters of high epilepsy-related ED visits were centred in the cities of Los Angeles, Oakland and Stockton and a large rural cluster centred in Kern County. No consistent pattern by age, race/ethnicity, household structure, and income was observed among all clusters. Regression found only the Los Angeles cluster significant after adjusting for other measures.

Conclusions

Geospatial analysis within a large and geographically diverse region identified a cluster within its most populous city having an increased risk of ED visits for epilepsy independent of selected socio-demographic and hospital measures. Additional research is necessary to determine whether elevated rates of ED visits represent increased prevalence of epilepsy or an inequitable system of epilepsy care.

A clinically oriented perspective on psychogenic nonepileptic seizure-related emergencies

Psychogenic nonepileptic seizures (PNES) can present emergently and are often mistaken for epileptic seizures. PNES emergencies have not been well studied, and yet there are associated serious morbidities, particularly when patients are seen in an emergency setting and are misdiagnosed. PNES may be prolonged, mimicking status epilepticus, a condition we refer to as nonepileptic psychogenic status (NEPS), and patients may receive aggressive and unnecessary medical treatments that can lead to serious iatrogenic complications, including death. NEPS is also associated with an increased risk of self-harm, including suicide attempts, and may indicate a serious comorbid psychiatric illness. In addition to iatrogenic complications of PNES, accidents and injuries are an underrecognized source of morbidity. PNES may also present during medical procedures, which may not only interfere with their completion, but may alarm practitioners who, fearing liability, may initiate further medical evaluations and treatments. When PNES occur during pregnancy, patients may be misdiagnosed with eclampsia and their offspring delivered prematurely. They also risk being placed on medications that are harmful to the fetus. Increased awareness of PNES is necessary to prevent iatrogenic harm and to identify underlying psychiatric illnesses that carry their own risks. As yet, data available to guide treatment are scant, and further study is needed.

Electroencephalography in the pediatric emergency department: when is it most useful?

This study aimed to identify the indications in which electroencephalography in the pediatric emergency department is most useful. We retrospectively reviewed the influence that the results of the emergent electroencephalogram had on the eventual disposition of patients at our pediatric emergency department. Sixty-eight children (mean age, 7.3 years; 32 males) underwent 70 emergent electroencephalograms. Fifty-seven emergent electroencephalograms were performed for the suspicion of ongoing seizures or status epilepticus. Thirteen of the 22 children (59.1%) discharged from the emergency department were sent home mainly based on the results of the emergent electroencephalogram, which prevented an admission. In particular, 11 of 38 children with frequent and recurrent paroxysmal events concerning for seizures and 2 of 19 children with suspected ongoing status epilepticus were discharged after excluding an epileptic disturbance. The emergent electroencephalogram provided meaningful clinical information that influenced disposition, especially in patients with ongoing events in which the clinical picture was clarified by a rapidly acquired electroencephalogram.

Emergency management of febrile status epilepticus: results of the FEBSTAT study

OBJECTIVE

Treatment of seizures varies by region, with no standard emergency treatment protocol. Febrile status epilepticus (FSE) is often a child's first seizure; therefore, families are rarely educated about emergency treatment.

METHODS

From 2002 to 2010, 199 subjects, age 1 month to 6 years, were recruited as part of a prospective, multicenter study of consequences of FSE, which was defined as a febrile seizure or series of seizures lasting >30 min. The patients' charts were reviewed. No standardized treatment protocol was implemented for this observational study.

RESULTS

One hundred seventy-nine children received at least one antiepileptic drug (AED) to terminate FSE, and more than one AED was required in 140 patients (70%). Median time from the seizure onset to first AED by emergency medical services (EMS) or emergency department (ED) was 30 min. Mean seizure duration was 81 min for subjects given medication prior to ED and 95 min for those who did not (p = 0.1). Median time from the first dose of AED to end of seizure was 38 min. Initial dose of lorazepam or diazepam was suboptimal in 32 (19%) of 166 patients. Ninety-five subjects (48%) received respiratory support by EMS or ED. Median seizure duration for the respiratory support group was 83 min; for the nonrespiratory support group the duration was 58 min (p-value < 0.001). Reducing the time from seizure onset to AED initiation was significantly related to shorter seizure duration.

SIGNIFICANCE

FSE rarely stops spontaneously, is fairly resistant to medications, and even with treatment persists for a significant period of time. The total seizure duration is composed of two separate factors, the time from seizure onset to AED initiation and the time from first AED to seizure termination. Earlier onset of treatment results in shorter total seizure duration. A standard prehospital treatment protocol should be used nationwide and education of EMS responders is necessary.

Profile of children admitted with seizures in a tertiary care hospital of Western Nepal

Background

Seizure is one of the common causes of childhood hospitalization with significant mortality and morbidity. There is limited data regarding acute seizures episodes form the developing countries. Current study aims to find the common etiology of seizure and classify seizure types in various age groups presenting to tertiary center in Western Nepal.

Methods

This was a hospital based retrospective study carried out in the data retrieved from the records maintained in the Department of Pediatrics, Manipal Teaching Hospital, Pokhara from 1^st July 2007 to 31^st July 2011.Variables collected were demographics, clinical presentations, laboratory tests, brain imaging studies, electroencephalography, diagnosis and hospital course.

Results

A total of 551 patients were admitted for seizures with 338 (61.3%) males and 213 (38.7%) females. Among these patients, 295 (53.5%) presented with fever and 317 (57.5%) of children were less than 5 years of age. Generalized tonic-clonic seizures were the most common seizure type (69.9%). Seizure disorder (33.4%), febrile seizures (30.7%), CNS infections and neurocysticercosis were common etiologies. Abnormal brain images were noted in 111 (45.9%) of 242 patients and most common abnormality was neurocysticercosis 66 (59.5%).

Conclusion

CNS infections and febrile convulsions were common causes of seizures in febrile children. Neuroimaging should be advised in all afebrile children for the diagnosis of neurocysticercosis. Children diagnosed as seizure disorder require long term follow up studies including neurophysiologic studies.

Comparison of serum zinc levels measured by inductively coupled plasma mass spectrometry in preschool children with febrile and afebrile seizures

Background

Changes in levels of trace elements have been proposed to underlie febrile seizures. Particularly, low zinc levels have been proposed as related factor of febrile seizure. In this study, we investigated whether mean serum zinc levels differed between children with febrile seizure and afebrile seizure.

Methods

Using inductively coupled plasma mass spectrometry, serum zinc levels were measured in 288 children who had been diagnosed with febrile seizures (N=248) and afebrile seizures (N=40). Mean serum zinc levels were compared between the 2 groups.

Results

Mean serum zinc level was 60.5±12.7 µg/dL in the febrile seizure group and 68.9 ±14.5 µg/dL in the afebrile seizure group. A significant difference in serum zinc levels was observed between the febrile and afebrile seizure groups (P<0.001).

Conclusions

Zinc levels in children with febrile seizure were significantly lower than those in children with afebrile seizure.