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Gifford A, Griffiths MJ, Rodie P, Wilmshurst J, Ball J, Dunkley C, McLellan A, O'Callaghan F, Kirkpatrick M. Reducing epilepsy diagnostic and treatment gaps: Standardized paediatric epilepsy training courses for health care professionals. Dev Med Child Neurol 2024; 66:1045-1052. [PMID: 38297494 DOI: 10.1111/dmcn.15864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 02/02/2024]
Abstract
AIM To evaluate improvement in knowledge and clinical behaviour among healthcare professionals after attendance at paediatric epilepsy training (PET) courses. METHOD Since 2005, 1-day PET courses have taught evidence-based paediatric epilepsy management to doctors and nurses in low-, middle-, and high-income countries. A cohort study was performed of 7528 participants attending 252 1-day PET courses between 2005 and 2020 in 17 low-, middle-, and high-income countries, and which gathered data from participants immediately after the course and then 6 months later. Training outcomes were measured prospectively in three domains (reaction, learning, and behaviour) using a mixed-methods approach involving a feedback questionnaire, a knowledge quiz before and after the course, and a 6-month survey. RESULTS Ninety-eight per cent (7217 of 7395) of participants rated the course as excellent or good. Participants demonstrated knowledge gain, answering a significantly higher proportion of questions correctly after the course compared to before the course (88% [47 883 of 54 196], correct answers/all quiz answers, vs 75% [40 424 of 54 196]; p < 0.001). Most survey responders reported that the course had improved their epilepsy diagnosis and management (73% [311 of 425]), clinical service (68% [290 of 427]), and local epilepsy training (68% [290 of 427]). INTERPRETATION This was the largest evaluation of a global epilepsy training course. Participants reported high course satisfaction, showed knowledge gain, and described improvements in clinical behaviour 6 months later. PET supports the global reduction in the epilepsy 'treatment gap' as promoted by the World Health Organization.
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Affiliation(s)
| | - Michael J Griffiths
- Paediatric Neuroscience, Alder Hey Children's NHS Foundation Trust, University of Liverpool, Liverpool, UK
| | | | - Jo Wilmshurst
- Paediatric Neurology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Jessica Ball
- British Paediatric Neurology Association, London, UK
| | - Colin Dunkley
- Paediatric Department, Sherwood Forest Hospitals NHS Foundation Trust, UK
| | - Ailsa McLellan
- Department of Paediatric Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Finbar O'Callaghan
- Department of Neuroscience, Great Ormond Street Hospital for Children, UCL Great Ormond Street Institute of Child Health, London, UK
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Rubinos C. Emergent Management of Status Epilepticus. Continuum (Minneap Minn) 2024; 30:682-720. [PMID: 38830068 DOI: 10.1212/con.0000000000001445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Status epilepticus is a neurologic emergency that can be life- threatening. The key to effective management is recognition and prompt initiation of treatment. Management of status epilepticus requires a patient-specific-approach framework, consisting of four axes: (1) semiology, (2) etiology, (3) EEG correlate, and (4) age. This article provides a comprehensive overview of status epilepticus, highlighting the current treatment approaches and strategies for management and control. LATEST DEVELOPMENTS Administering appropriate doses of antiseizure medication in a timely manner is vital for halting seizure activity. Benzodiazepines are the first-line treatment, as demonstrated by three randomized controlled trials in the hospital and prehospital settings. Benzodiazepines can be administered through IV, intramuscular, rectal, or intranasal routes. If seizures persist, second-line treatments such as phenytoin and fosphenytoin, valproate, or levetiracetam are warranted. The recently published Established Status Epilepticus Treatment Trial found that all three of these drugs are similarly effective in achieving seizure cessation in approximately half of patients. For cases of refractory and super-refractory status epilepticus, IV anesthetics, including ketamine and γ-aminobutyric acid-mediated (GABA-ergic) medications, are necessary. There is an increasing body of evidence supporting the use of ketamine, not only in the early phases of stage 3 status epilepticus but also as a second-line treatment option. ESSENTIAL POINTS As with other neurologic emergencies, "time is brain" when treating status epilepticus. Antiseizure medication should be initiated quickly to achieve seizure cessation. There is a need to explore newer generations of antiseizure medications and nonpharmacologic modalities to treat status epilepticus.
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Edridge A, Namazzi R, Tebulo A, Mfizi A, Deijs M, Koekkoek S, de Wever B, van der Ende A, Umiwana J, de Jong MD, Jans J, Verhoeven-Duif N, Titulaer M, van Karnebeek C, Seydel K, Taylor T, Asiimwe-Kateera B, van der Hoek L, Kabayiza JC, Mallewa M, Idro R, Boele van Hensbroek M, van Woensel JBM. Viral, Bacterial, Metabolic, and Autoimmune Causes of Severe Acute Encephalopathy in Sub-Saharan Africa: A Multicenter Cohort Study. J Pediatr 2023; 258:113360. [PMID: 36828342 DOI: 10.1016/j.jpeds.2023.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 02/11/2023] [Accepted: 02/19/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES To assess whether viral, bacterial, metabolic, and autoimmune diseases are missed by conventional diagnostics among children with severe acute encephalopathy in sub-Saharan Africa. STUDY DESIGN One hundred thirty-four children (6 months to 18 years) presenting with nontraumatic coma or convulsive status epilepticus to 1 of 4 medical referral centers in Uganda, Malawi, and Rwanda were enrolled between 2015 and 2016. Locally available diagnostic tests could be supplemented in 117 patients by viral, bacterial, and 16s quantitative polymerase chain reaction testing, metagenomics, untargeted metabolomics, and autoimmune immunohistochemistry screening. RESULTS Fourteen (12%) cases of viral encephalopathies, 8 (7%) cases of bacterial central nervous system (CNS) infections, and 4 (4%) cases of inherited metabolic disorders (IMDs) were newly identified by additional diagnostic testing as the most likely cause of encephalopathy. No confirmed cases of autoimmune encephalitis were found. Patients for whom additional diagnostic testing aided causal evaluation (aOR 3.59, 90% CI 1.57-8.36), patients with a viral CNS infection (aOR 7.91, 90% CI 2.49-30.07), and patients with an IMD (aOR 9.10, 90% CI 1.37-110.45) were at increased risk for poor outcome of disease. CONCLUSIONS Viral and bacterial CNS infections and IMDs are prevalent causes of severe acute encephalopathy in children in Uganda, Malawi, and Rwanda that are missed by conventional diagnostics and are associated with poor outcome of disease. Improved diagnostic capacity may increase diagnostic yield and might improve outcome of disease.
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Affiliation(s)
- Arthur Edridge
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Ruth Namazzi
- Department of Paediatrics, Makerere University, Kampala, Uganda
| | - Andrew Tebulo
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Anan Mfizi
- Department of Paediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Martin Deijs
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sylvie Koekkoek
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bob de Wever
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arie van der Ende
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeanine Umiwana
- Department of Paediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Menno D de Jong
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Judith Jans
- Laboratory of Metabolic Diseases, UMC Utrecht, Utrecht, The Netherlands
| | | | | | - Clara van Karnebeek
- Departments of Pediatrics and Human Genetics, Emma Center for Personalized Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Karl Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
| | - Terrie Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
| | | | - Lia van der Hoek
- Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jean-Claude Kabayiza
- Department of Paediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Macpherson Mallewa
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Richard Idro
- Department of Paediatrics, Makerere University, Kampala, Uganda
| | - Michael Boele van Hensbroek
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Paediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands
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The Next Frontier in Neurocritical Care in Resource-Constrained Settings. Crit Care Clin 2022; 38:721-745. [PMID: 36162907 DOI: 10.1016/j.ccc.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Neurocritical care (NCC) is an emerging field within critical care medicine, reflecting the widespread prevalence of neurologic injury in critically ill patients. Morbidity and mortality from neurocritical illness (NCI) have been reduced substantially in resource-rich settings (RRS), owing to the development of advanced technologies, neuro-specific units, and subspecialized medical training. Despite shouldering much of the burden of NCI worldwide, resource-limited settings (RLS) face immense hurdles when implementing guidelines generated in RRS. This review summarizes the current epidemiology, management, and outcomes of the most common NCIs in RLS and offers commentary on future directions in NCC practiced in RLS.
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Langat NK, Kariuki SM, Kamuyu G, Kakooza-Mwesige A, Owusu-Agyei S, Ae-Ngibise K, Wang'ombe A, Ngugi AK, Masaja H, Wagner RG, Newton CR. Exposure to parasitic infections determines features and phenotypes of active convulsive epilepsy in Africa. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.17049.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Epilepsy affects 70 million people worldwide, 80% of whom are in low-and-middle income countries (LMICs). Parasitic infections contribute considerably to the burden of epilepsy in LMICs, but the nature and presentation of epilepsy following these infections is not fully understood. We examined if epilepsy outcomes are associated with the exposure to parasitic infections. Methods: This was a case-comparison study nested in a cross-sectional survey of people with active convulsive epilepsy, with cases as those exposed to parasitic infections, and comparison as those unexposed. Associations of exposure to parasites with clinical and electroencephalographic features of epilepsy were done using a modified mixed effects Poisson regression model across five sites in Africa. Multiplicative and additive scale (RERI) interactions were explored to determine the effect of co-infections on epilepsy features. Population attributable fractions (PAF) were calculated to determine the proportion of severe clinical and electroencephalographic features of epilepsy attributable to parasitic infections. Results: A total of 997 participants with active convulsive epilepsy from the five African sites were analyzed, 51% of whom were males. Exposure to parasitic infections was associated with more frequent seizures in adult epilepsy (relative risk (RR)=2.58, 95% confidence interval (95%CI):1.71-3.89). In children, exposure to any parasite was associated with convulsive status epilepticus (RR=4.68, (95%CI: 3.79-5.78), intellectual disabilities (RR=2.13, 95%CI: 1.35-3.34) and neurological deficits (RR=1.92, 95%CI: 1.42-2.61). Toxoplasma gondii and Onchocerca volvulus interacted synergistically to increase the risk of status epilepticus (RERI=0.91, 95%CI=0.48-1.35) in the data pooled across the sites. Exposure to parasitic infections contributed to 30% of severe features of epilepsy as shown by PAF. Conclusions: Parasitic infections may determine features and phenotypes of epilepsy through synergistic or antagonistic interactions, which can be different in children and adults. Interventions to control or manage infections may reduce complications and improve prognosis in people with epilepsy.
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Why won't it stop? The dynamics of benzodiazepine resistance in status epilepticus. Nat Rev Neurol 2022; 18:428-441. [PMID: 35538233 DOI: 10.1038/s41582-022-00664-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/08/2022]
Abstract
Status epilepticus is a life-threatening neurological emergency that affects both adults and children. Approximately 36% of episodes of status epilepticus do not respond to the current preferred first-line treatment, benzodiazepines. The proportion of episodes that are refractory to benzodiazepines is higher in low-income and middle-income countries (LMICs) than in high-income countries (HICs). Evidence suggests that longer episodes of status epilepticus alter brain physiology, thereby contributing to the emergence of benzodiazepine resistance. Such changes include alterations in GABAA receptor function and in the transmembrane gradient for chloride, both of which erode the ability of benzodiazepines to enhance inhibitory synaptic signalling. Often, current management guidelines for status epilepticus do not account for these duration-related changes in pathophysiology, which might differentially impact individuals in LMICs, where the average time taken to reach medical attention is longer than in HICs. In this Perspective article, we aim to combine clinical insights and the latest evidence from basic science to inspire a new, context-specific approach to efficiently managing status epilepticus.
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Pathania V, Guglani V, Azad C, Jain S, Kaur R, Singh DK. Disability and Mortality in Convulsive Status Epilepticus in Children at 3 Months' Follow-Up: A Prospective Study from India. J Neurosci Rural Pract 2022; 13:211-217. [PMID: 35694062 PMCID: PMC9187372 DOI: 10.1055/s-0042-1743212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background
Convulsive status epilepticus (CSE) is a common neurological emergency with high mortality, morbidity, and poor quality of life. There is a paucity of follow-up studies from developing nations in pediatric age group.
Objectives
This article looks for clinico-etiological profile of CSE and estimates the immediate and short-term mortality in children with CSE and its predictive factors.
Methodology
This prospective longitudinal study was done at a tertiary care institute of Northern India. The patients between the ages of 1 and 16 years with CSE were enrolled after informed consent, they were observed in the hospital, and survived patients were followed till 3 months after discharge.
Results
A total of 200 patients (58% males) were enrolled. Acute symptomatic (63.5%) was the most common etiology. Twenty-five (12.5%) patients died during hospital stay; at discharge, 160 (80%) had good recovery and rest had a varying range of disability. The predictive factors for poor outcome were female gender, duration of CSE > 1 hour at presentation, generalized seizures, Glasgow Coma Scale < 8 at presentation, refractory status epilepticus, need for critical care support, and acute symptomatic etiology. On follow-up, two patients died at 1-month and one at 3-month follow-up, the cause of death was probably seizures in two patients and feed aspiration in one patient. Seven patients deteriorated from good recovery scoring to moderate disability during the time interval between first and second follow-up, none of them reported apparent repeat seizures.
Conclusion
Pediatric CSE is associated with immediate poor outcome; risk of death and new disabilities persist after discharge thus proper follow-up is essential.
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Affiliation(s)
- Vansha Pathania
- Department of Paediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Vishal Guglani
- Department of Paediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Chandrika Azad
- Department of Paediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Suksham Jain
- Department of Neonatology, Government Medical College and Hospital, Chandigarh, India
| | - Ravinder Kaur
- Department of Radiodiagnosis, Government Medical College and Hospital, Chandigarh, India
| | - Dharmendra Kumar Singh
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Jayalakshmi S, Patil A, Challa A, Parekh M, Khandelia H, Vooturi S. Determinants of mortality and long-term outcome in children with refractory and super refractory status epilepticus. J Clin Neurosci 2022; 97:12-16. [PMID: 35030458 DOI: 10.1016/j.jocn.2021.12.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022]
Abstract
AIM To evaluate factors associated with progression of convulsive refractory status epilepticus(RSE) to super refractory status epilepticus(SRSE) and long term outcome in children. MATERIALS AND METHODS In this open cohort study, data of children admitted with convulsive RSE from 2010 to 2018 was retrospectively analyzed. The outcome at two years was graded according to the Glasgow outcome scale(GOS). RESULTS Fifty six children formed study population, 24 progressed to SRSE. The mean age of the study population was 9.38 ± 4.28(2-16) years. There was no significant difference for age between SRSE and RSE children (9.53 ± 4.50 years vs. 9.17 ± 4.06 years; p = 0.756). Acute symptomatic aetiology was the most common aetiology for RSE (57.1%) and SRSE (54.2%). There were no differences for aetiology between children who progressed to SRSE and those who did not. Mean length of stay in the NICU was 13.54 ± 17.53 days and children who progressed to SRSE had a longer length of stay in NICU (4.78 ± 3.03 days vs. 25.21 ± 21.77 days; p < 0.001). The mortality was 14.2%. Acidosis was more common in children who died (27.1% vs. 87.5%;p < 0.001). There was no significant difference in the mortality between RSE and SRSE (9.4% vs. 20.8%; p = 0.268). At latest follow up 34 (60.7%) children had good outcome. Poor outcome was more common in children who progressed to SRSE(29.4% vs. 63.6%;p < 0.015). CONCLUSION Acute symptomatic etiology is more frequent in children with RSE and SRSE. Progression to SRSE did not significantly increase mortality but associated with poor GOS outcome. Encouragingly, 60% of children had good outcome.
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Affiliation(s)
- Sita Jayalakshmi
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, India.
| | - Anuja Patil
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, India
| | - Anusha Challa
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, India
| | - Mihir Parekh
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, India
| | - Harsh Khandelia
- Department of Neuro-critical Care, Krishna Institute of Medical Sciences, Secunderabad, India
| | - Sudhindra Vooturi
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, India
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Marshall C, Olaniyan T, Jalloh AA, Jabang JN, Kirunda A, Njohjam MN, Olusola BM, Karway TZ, Shabangu E, Kagema J, Malunga A, Kazadi P, Kumwenda M, Kinney M. Survey of the perceived treatment gap in status epilepticus care across Sub-Saharan countries from the perspective of healthcare providers. Epilepsy Behav 2021; 125:108408. [PMID: 34839239 DOI: 10.1016/j.yebeh.2021.108408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/04/2021] [Accepted: 10/23/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Status epilepticus (SE) is a serious condition disproportionately affecting Sub-Saharan African (SSA) countries. Little is known about healthcare provider experiences. This study investigated the healthcare provider perspective of SE care. METHODS A pilot questionnaire was developed for healthcare professionals in SSA countries. It was distributed online at a conference concerning epilepsy care and local coordinators distributed the questionnaire in their networks. It was available online between 16th Jan and 1st Feb 2021. The unvalidated questionnaire questioned practitioner demographics, experience, confidence in SE care, common etiologies encountered, anticipated prognosis in their setting, available treatments, and barriers to care. We assessed practitioner perceptions not their knowledge base around SE care. Thematic analysis was used for open-ended questions. RESULTS Fifty nine responses were received from 11 countries. Respondents (44% nurses, 46% doctors) reported poor level of adequate SE training (mean self-reported confidence in training 2.9/10 (0/10 very inadequate and 10/10 very adequate training). Delays in arriving at hospital were common with 15 (32%) taking three or more hours and 28 (62%) proposing transport issues and distance were the main reasons for delay. Urban location was significantly associated with clinician confidence. Less than 20% used prehospital benzodiazepine treatment. 46 (78%) stated benzodiazepines were first-line hospital drug management, and 52 (88%) indicated alternative second-line hospital treatments were available. CONCLUSION A substantial perceived treatment gap in the management of SE in SSA is identified by staff working in SSA. Key issues are around staff training, patient education, medication access, and compliance.
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Affiliation(s)
| | | | - Alhaji Alusine Jalloh
- Department of Paediatrics and Child Health, University of Sierra Leone Teaching Hospitals Complex, Sierra Leone
| | | | | | | | | | | | - Edward Shabangu
- Mbabane Government Hospital, Psychiatric Unit - Epilepsy, Eswatini
| | | | | | | | | | - Michael Kinney
- Department of Neurology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK.
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Sood S, Azad C, Kaur J, Kumar P, Guglani V, Singla S. Role of cerebrospinal fluid tau protein levels as a biomarker of brain injury in pediatric status epilepticus. Int J Neurosci 2021:1-9. [PMID: 34473934 DOI: 10.1080/00207454.2021.1976172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Various biomarkers have been studied for predicting etiology and outcome in status epilepticus (SE); cerebrospinal fluid (CSF) total tau (t-tau) protein levels is foremost among them. Only handful of studies are available regarding role of t-tau in childhood SE. METHODOLOGY This prospective study was conducted in a tertiary care center of Northern India in children 6 months -12 years of age. The Cases were patients with convulsive status epilepticus (CSE) whereas Controls were patients without SE and normal CSF. The t-tau levels were done in CSF of both the groups. The outcome was assessed by GOS-E Peds score. RESULTS A total of 50 (62% males) cases and 15 (67% males) controls were enrolled in the study. SE was generalized in 78% cases whereas 14% had refractory SE. Most common etiology of CSE was acute symptomatic (52%), followed by prolonged febrile seizure (24%), remote symptomatic group (14%), unknown etiology (8%) and progressive disorder (2%). Case fatality rate was 10%. Poor outcome was seen in 30% cases. Median (IQR) CSF t-tau levels was significantly lower 2.6 × 103 (0.5-9.4 × 103) pg/ml in cases vs 10.6 × 103 (6.0-14.2 × 103) pg/ml in controls (p = 0.004). There was no significant correlation seen between type, duration, etiology and response to antiepileptic drugs of SE with CSF t-tau levels. Also, no significant correlation of poor sensorium, outcome of SE and critical care needs with CSF t-tau levels was noted. CONCLUSION CSF t-tau is not a useful diagnostic or prognostic biomarker in pediatric SE.
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Affiliation(s)
- Shivanjali Sood
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Chandrika Azad
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Jasbinder Kaur
- Department of Biochemistry, Government Medical College and Hospital, Chandigarh, India
| | - Pankaj Kumar
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Vishal Guglani
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Seema Singla
- Department of Biochemistry, Government Medical College and Hospital, Chandigarh, India
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Ng MC, Pavlova M. Status epilepticus in the Canadian Arctic: A public health imperative hidden in plain sight. Epilepsia Open 2021; 6:703-713. [PMID: 34510825 PMCID: PMC8633482 DOI: 10.1002/epi4.12538] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/18/2021] [Accepted: 09/04/2021] [Indexed: 02/02/2023] Open
Abstract
Objective The World Health Organization, International League Against Epilepsy (ILAE), and International Bureau for Epilepsy have called epilepsy a public health imperative, with appropriate emphasis on low‐to‐middle‐income countries (LMIC). Although Canada is a high‐income country (HIC), income is not distributed uniformly. Furthermore, epilepsy data from the national statistical agency explicitly overlook the Arctic by excluding these territories. A common neurologic emergency, status epilepticus (SE) is a life‐threatening manifestation of epilepsy that demands prompt treatment to avoid death and long‐term sequelae. Therefore, we examined the rate of SE in a well‐defined Canadian Arctic region. Methods This study takes epidemiologic advantage of the Kivalliq Region's geographical isolation, which is accessible only by air. All SE patients requiring emergency care are consistently flown 1200‐1900 kilometers to a single designated hospital in a distinct southern part of Canada for further management and electroencephalography (EEG). We conducted a retrospective database and chart review at this “bottleneck” hospital to identify patients with seizure(s) severe enough to justify emergency airborne medical evacuation over a 11.25‐year period from 2009 to 2020. Results We screened 40 392 EEGs to yield 117 distinct medical evacuations for “operational SE” from 99 patients to derive estimated SE incidences of 99.9 evacuations per 100 000/year and 84.5 patients per 100 000/year. The average time from seizure onset to EEG was 3.2 days. Only 16.2% of SE patients had known epilepsy. For “confirmed SE” cases meeting ILAE criteria, or cases with persistently epileptiform EEG despite days of empiric treatment, estimated incidence was 77.7 evacuations per 100 000/year and 64.9 patients per 100 000/year. Significance High SE and epilepsy rates in the Canadian Arctic are consistent with LMIC rather than HIC. Our findings demonstrate the paradox of LMIC‐equivalent epilepsy populations camouflaged within HIC. Our findings also highlight the long‐standing plight of these under‐served and overlooked populations hidden in plain sight.
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Affiliation(s)
- Marcus C Ng
- Section of Neurology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Milena Pavlova
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Langat NK, Kariuki SM, Kamuyu G, Kakooza-Mwesige A, Owusu-Agyei S, Ae-Ngibise K, Wang'ombe A, Ngugi AK, Masaja H, Wagner RG, Newton CR. Exposure to parasitic infections determines features and phenotypes of active convulsive epilepsy in Africa. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.17049.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Epilepsy affects 70 million people worldwide, 80% of whom are in low-and-middle income countries (LMICs). Infections of the central nervous system (CNS) contribute considerably to the burden of epilepsy in LMICs, but the nature and presentation of epilepsy following these infections is not fully understood. We examined if epilepsy foutcomes are associated with the exposure to parasitic infections. Methods: This was a case-comparison study nested in a cross-sectional survey of people with active convulsive epilepsy, with cases as those exposed to parasitic infections, and comparison as those unexposed. Associations of exposure to parasites with clinical and electroencephalographic features of epilepsy were done using a modified mixed effects Poisson regression model across five sites in Africa. Multiplicative and additive scale (RERI) interactions were explored to determine the effect of co-infections on epilepsy features. Population attributable fractions (PAF) were calculated to determine the proportion of severe clinical and electroencephalographic features of epilepsy attributable to CNS infections. Results: A total of 997 participants with active convulsive epilepsy from the five African sites were analyzed, 51% of whom were males. Exposure to parasitic infections was associated with more frequent seizures in adult epilepsy (relative risk (RR)=2.58, 95% confidence interval (95%CI):1.71-3.89). In children, exposure to any parasite was associated with convulsive status epilepticus (RR=4.68, (95%CI: 3.79-5.78), intellectual disabilities (RR=2.13, 95%CI: 1.35-3.34) and neurological deficits (RR=1.92, 95%CI: 1.42-2.61). Toxoplasma gondii and Onchocerca volvulus interacted synergistically to increase the risk of status epilepticus (RERI=0.91, 95%CI=0.48-1.35) in the data pooled across the sites. Exposure to parasitic infections contributed to 30% of severe features of epilepsy as shown by PAF. Conclusions: Parasitic infections may determine features and phenotypes of epilepsy through synergistic or antagonistic interactions, which can be different in children and adults. Interventions to control or manage infections may reduce complications and improve prognosis in epilepsy.
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Gaínza-Lein M, Barcia Aguilar C, Piantino J, Chapman KE, Sánchez Fernández I, Amengual-Gual M, Anderson A, Appavu B, Arya R, Brenton JN, Carpenter JL, Clark J, Farias-Moeller R, Gaillard WD, Glauser TA, Goldstein JL, Goodkin HP, Huh L, Kahoud R, Kapur K, Lai YC, McDonough TL, Mikati MA, Morgan LA, Nayak A, Novotny E, Ostendorf AP, Payne ET, Peariso K, Reece L, Riviello J, Sannagowdara K, Sands TT, Sheehan T, Tasker RC, Tchapyjnikov D, Vasquez A, Wainwright MS, Wilfong A, Williams K, Zhang B, Loddenkemper T. Factors associated with long-term outcomes in pediatric refractory status epilepticus. Epilepsia 2021; 62:2190-2204. [PMID: 34251039 PMCID: PMC9291041 DOI: 10.1111/epi.16984] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study was undertaken to describe long-term clinical and developmental outcomes in pediatric refractory status epilepticus (RSE) and identify factors associated with new neurological deficits after RSE. METHODS We performed retrospective analyses of prospectively collected observational data from June 2011 to March 2020 on pediatric patients with RSE. We analyzed clinical outcomes from at least 30 days after RSE and, in a subanalysis, we assessed developmental outcomes and evaluated risk factors in previously normally developed patients. RESULTS Follow-up data on outcomes were available in 276 patients (56.5% males). The median (interquartile range [IQR]) follow-up duration was 1.6 (.9-2.7) years. The in-hospital mortality rate was 4% (16/403 patients), and 15 (5.4%) patients had died after hospital discharge. One hundred sixty-six (62.9%) patients had subsequent unprovoked seizures, and 44 (16.9%) patients had a repeated RSE episode. Among 116 patients with normal development before RSE, 42 of 107 (39.3%) patients with available data had new neurological deficits (cognitive, behavioral, or motor). Patients with new deficits had longer median (IQR) electroclinical RSE duration than patients without new deficits (10.3 [2.1-134.5] h vs. 4 [1.6-16] h, p = .011, adjusted odds ratio = 1.003, 95% confidence interval = 1.0008-1.0069, p = .027). The proportion of patients with an unfavorable functional outcome (Glasgow Outcome Scale-Extended score ≥ 4) was 22 of 90 (24.4%), and they were more likely to have received a continuous infusion. SIGNIFICANCE About one third of patients without prior epilepsy developed recurrent unprovoked seizures after the RSE episode. In previously normally developing patients, 39% presented with new deficits during follow-up, with longer electroclinical RSE duration as a predictor.
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Affiliation(s)
- Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Institute of Pediatrics, Faculty of Medicine, Austral University of Chile, Valdivia, Chile.,Children's Neuropsychiatry Service, San Borja Arriarán Clinical Hospital, University of Chile, Santiago, Chile
| | - Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Child Neurology, La Paz University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Juan Piantino
- Division of Neurology, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA
| | - Kevin E Chapman
- Phoenix Children's Hospital, Phoenix, Arizona, USA.,Departments of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Child Neurology, SJD Barcelona Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Pediatric Neurology Unit, Department of Pediatrics, Son Espases University Hospital, University of the Balearic Islands, Palma, Spain
| | - Anne Anderson
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Brian Appavu
- Department of Pediatrics, University of Arizona College of Medicine and Barrow's Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Ravindra Arya
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - James Nicholas Brenton
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jessica L Carpenter
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Justice Clark
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raquel Farias-Moeller
- Department of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - William D Gaillard
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Tracy A Glauser
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Joshua L Goldstein
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Howard P Goodkin
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Linda Huh
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, British Columbia, Canada
| | - Robert Kahoud
- Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kush Kapur
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Chen Lai
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Tiffani L McDonough
- Department of Pediatrics, Division of Neurology and Epilepsy, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, North Carolina, USA
| | - Lindsey A Morgan
- Department of Neurology, Division of Child Neurology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Anuranjita Nayak
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Edward Novotny
- Department of Neurology, Division of Child Neurology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Adam P Ostendorf
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Eric T Payne
- Division of Neurology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Katrina Peariso
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Latania Reece
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James Riviello
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Kumar Sannagowdara
- Department of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Tristan T Sands
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
| | - Theodore Sheehan
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dmitry Tchapyjnikov
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, North Carolina, USA
| | - Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Child and Adolescent Neurology, Mayo Clinic, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mark S Wainwright
- Department of Neurology, Division of Child Neurology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Angus Wilfong
- Department of Pediatrics, University of Arizona College of Medicine and Barrow's Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Korwyn Williams
- Department of Pediatrics, University of Arizona College of Medicine and Barrow's Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Bo Zhang
- Department of Neurology, Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ascoli M, Ferlazzo E, Gasparini S, Mastroianni G, Citraro R, Roberti R, Russo E. Epidemiology and Outcomes of Status Epilepticus. Int J Gen Med 2021; 14:2965-2973. [PMID: 34234526 PMCID: PMC8254099 DOI: 10.2147/ijgm.s295855] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/15/2021] [Indexed: 12/25/2022] Open
Abstract
Status epilepticus (SE) is a neurological and medical emergency, defined as a condition resulting either from the failure of the mechanisms responsible of seizure self-limitation or from the initiation of mechanisms which lead to atypically prolonged seizures. Further than death, SE can have long-term consequences, including neuronal injury, depending on the type, cause and duration of seizures with severe associated disabilities. In Europe, SE shows an incidence rate ranging about 9 to 40/100,000/y. In adults, mortality of patients with SE is ~30%, and even higher (up to 40%) in refractory status epilepticus. To date, etiology, duration, presence of comorbidity, level of consciousness, semiology and age are the main clinical predictors of SE outcome.
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Affiliation(s)
- Michele Ascoli
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio, Calabria, Italy
| | - Edoardo Ferlazzo
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio, Calabria, Italy
| | - Sara Gasparini
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio, Calabria, Italy
| | | | - Rita Citraro
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
| | - Roberta Roberti
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
| | - Emilio Russo
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
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15
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Abuga JA, Kariuki SM, Kinyanjui SM, Boele van Hensbroek M, Newton CR. Premature Mortality, Risk Factors, and Causes of Death Following Childhood-Onset Neurological Impairments: A Systematic Review. Front Neurol 2021; 12:627824. [PMID: 33897590 PMCID: PMC8062883 DOI: 10.3389/fneur.2021.627824] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/11/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Neurological impairment (NI) and disability are associated with reduced life expectancy, but the risk and magnitude of premature mortality in children vary considerably across study settings. We conducted a systematic review to estimate the magnitude of premature mortality following childhood-onset NI worldwide and to summarize known risk factors and causes of death. Methods: We searched various databases for published studies from their inception up to 31st October 2020. We included all cohort studies that assessed the overall risk of mortality in individuals with childhood-onset epilepsy, intellectual disability (ID), and deficits in hearing, vision and motor functions. Comparative measures of mortality such as the standardized mortality ratio (SMR), risk factors and causes were synthesized quantitatively under each domain of impairment. This review is registered on the PROSPERO database (registration number CRD42019119239). Results: The search identified 2,159 studies, of which 24 studies were included in the final synthesis. Twenty-two (91.7%) studies originated from high-income countries (HICs). The median SMR was higher for epilepsy compared with ID (7.1 [range 3.1-22.4] vs. 2.9 [range 2.0-11.6]). In epilepsy, mortality was highest among younger age groups, comorbid neurological disorders, generalized seizures (at univariable levels), untreatable epilepsy, soon after diagnosis and among cases with structural/metabolic types, but there were no differences by sex. Most deaths (87.5%) were caused by non-epilepsy-related causes. For ID, mortality was highest in younger age groups and girls had a higher risk compared to the general population. Important risk factors for premature mortality were severe-to-profound severity, congenital disorders e.g., Down Syndrome, comorbid neurological disorders and adverse pregnancy and perinatal events. Respiratory infections and comorbid neurological disorders were the leading causes of death in ID. Mortality is infrequently examined in impairments of vision, hearing and motor functions. Summary: The risk of premature mortality is elevated in individuals with childhood-onset NI, particularly in epilepsy and lower in ID, with a need for more studies for vision, hearing, and motor impairments. Survival in NI could be improved through interventions targeting modifiable risk factors and underlying causes.
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Affiliation(s)
- Jonathan A. Abuga
- Kenya Medical Research Institute (KEMRI-Wellcome Trust Research Programme), Clinical Research (Neurosciences), Kilifi, Kenya
- Global Child Health Group, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Symon M. Kariuki
- Kenya Medical Research Institute (KEMRI-Wellcome Trust Research Programme), Clinical Research (Neurosciences), Kilifi, Kenya
- Department of Public Health, Pwani University, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Samson M. Kinyanjui
- Kenya Medical Research Institute (KEMRI-Wellcome Trust Research Programme), Clinical Research (Neurosciences), Kilifi, Kenya
- Department of Public Health, Pwani University, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Michael Boele van Hensbroek
- Global Child Health Group, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Charles R. Newton
- Kenya Medical Research Institute (KEMRI-Wellcome Trust Research Programme), Clinical Research (Neurosciences), Kilifi, Kenya
- Department of Public Health, Pwani University, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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16
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Abstract
Context Refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE) are neurological emergencies with considerable mortality and morbidity. In this paper, we provide an overview of causes, evaluation, treatment, and consequences of RSE and SRSE, reflecting the lack of high-quality evidence to inform therapeutic approach. Sources This is a narrative review based on personal practice and experience. Nevertheless, we searched MEDLINE (using PubMed and OvidSP vendors) and Cochrane central register of controlled trials, using appropriate keywords to incorporate recent evidence. Results Refractory status epilepticus is commonly defined as an acute convulsive seizure that fails to respond to two or more anti-seizure medications including at least one nonbenzodiazepine drug. Super-refractory status epilepticus is a status epilepticus that continues for ≥24 hours despite anesthetic treatment, or recurs on an attempted wean of the anesthetic regimen. Both can occur in patients known to have epilepsy or de novo, with increasing recognition of autoimmune and genetic causes. Electroencephalography monitoring is essential to monitor treatment response in refractory/super-refractory status epilepticus, and to diagnose non-convulsive status epilepticus. The mainstay of treatment for these disorders includes anesthetic infusions, primarily midazolam, ketamine, and pentobarbital. Dietary, immunological, and surgical treatments are viable in selected patients. Management is challenging due to multiple acute complications and long-term adverse consequences. Conclusions We have provided a synopsis of best practices for diagnosis and management of refractory/superrefractory status epilepticus and highlighted the lack of sufficient high-quality evidence to drive decision making, ending with a brief foray into avenues for future research.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Lisa Garrity
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; USA. Correspondence to: Dr Ravindra Arya, Division of Neurology, Cincinnati Children's Hospital Medical Center, MLC 2015, 3333 Burnet Avenue, Cincinnati, Ohio, 45229 USA.
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17
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Lu M, Faure M, Bergamasco A, Spalding W, Benitez A, Moride Y, Fournier M. Epidemiology of status epilepticus in the United States: A systematic review. Epilepsy Behav 2020; 112:107459. [PMID: 33181886 DOI: 10.1016/j.yebeh.2020.107459] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Convulsive status epilepticus (CSE) is a life-threatening neurologic emergency, which is defined by the International League Against Epilepsy (ILAE) as bilateral tonic-clonic seizure activity lasting longer than 5 min, while absence status epilepticus (SE) and focal SE are specified as exceeding 10 min. Epidemiological evidence on SE is currently lacking, and the incidence is not well-known, especially in light of changes in the ILAE criteria for SE. The objectives of this systematic literature review were to describe the epidemiology of SE in the US population and the associated burden of illness. METHODS A systematic review, including literature and pragmatic searches, was conducted. Literature searches were performed using MEDLINE, Embase, BIOSIS, and Web of Science electronic databases from inception to February 2019. Pragmatic searches of the gray literature were carried out using Google, Google Scholar, conference proceedings, and ClinicalTrials.gov to identify additional sources. Only US-based studies or multinational studies reporting US data of interest were included. RESULTS In total, 69 sources were identified. The incidence of all SE in patients of all ages in the USA ranged from 18.3 to 41 per 100,000 people per year. Incidence of all-age CSE rose from 3.5 (1979) to 12.5 (2010) per 100,000 people per year. Status epilepticus incidence followed a bimodal (U-shaped) distribution, with the highest estimates in the first years of life (0-4 years) and after 60 years. Mortality associated with SE varied from 21% over 30 days to 31.2% over 10 years. For CSE, two studies reported similar in-hospital mortalities (9.2% and 10.7%). Median healthcare costs related to SE admission were approximately US$14,500 per adult (17-45 years) and US$8000 per child (0-16 years). CONCLUSIONS There is a lack of recent data on the epidemiology and healthcare burden associated with SE. Reports of SE incidence in the USA are highly variable and predate the 2015 ILAE definition of SE. However, the available data suggest a high burden of illness.
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Affiliation(s)
- Mei Lu
- Shire Development LLC, a Takeda company, Lexington, MA, United States of America.
| | - Mareva Faure
- YOLARX Consultants Inc., Montreal, Quebec, Canada
| | | | - William Spalding
- Shire Development LLC, a Takeda company, Lexington, MA, United States of America
| | - Arturo Benitez
- Shire Development LLC, a Takeda company, Lexington, MA, United States of America
| | - Yola Moride
- YOLARX Consultants Inc., Montreal, Quebec, Canada; YOLARX Consultants SARL, Paris, France; Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada; Rutgers, The State University of New Jersey, New Brunswick, NJ, United States of America
| | - Martha Fournier
- Shire Development LLC, a Takeda company, Lexington, MA, United States of America
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18
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Das K, Das SK, Pradhan S, Sahoo PI, Mohakud NK, Swain A, Satpathy S. Clinical Feature and Outcome of Childhood Status Epilepticus in a Teaching Hospital, Odisha, India. Cureus 2020; 12:e10927. [PMID: 33194493 PMCID: PMC7657569 DOI: 10.7759/cureus.10927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Objectives The main aim is to find out the clinical feature and outcome of status epilepticus (SE) in children managed in a teaching hospital. The secondary aim is to identify the risk factors influencing the adverse outcomes. Methods In this prospective cohort, children aged 1 month to 14 years with SE as per the International League Against Epilepsy’s new guideline (2016) who presented to the emergency department during the period of November 2017 to October 2019 were enrolled. Clinical profile, treatment, and outcome of cases (n = 94) were noted. Results The majority of children, 60 (63.82%), were less than five years of age. Prior history of seizures was present in 33 (35.1%) cases, whereas 61 (64.9%) cases presented with SE as the first episode of seizure. In 14 (42.4%) previous seizure cases, SE was due to drug default. No response to first-line antiepileptic drug (AED) was seen in 84 (89.37%) cases. Acute symptomatic etiology was the commonest etiology of SE in 64 (68%) cases, of which neuro-infections accounted for 44 (46.80%) cases. Longer duration (>60 minutes) of status (p < 0.01), ventilator support (p < 0.0001), and circulatory impairment (p < 0.0001) were attributable risk factors for mortality. A total of 28 children died (mortality rate, 29.8%), and 11 showed the persistence of their neuro-deficit. Conclusions Neuro-infection is the most common etiology of SE in children. Longer duration of SE, more lag time for receiving the first AED, respiratory failure, and presence of shock are independent predictors for poor outcome. Hence, cessation of convulsion at the earliest leads to improved outcomes.
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Affiliation(s)
- Kedarnath Das
- Pediatrics, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, IND
| | - Santosh K Das
- Pediatrics, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, IND
| | | | | | - Nirmal K Mohakud
- Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Arakhita Swain
- Pediatrics, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, IND
| | - Saroj Satpathy
- Pediatrics, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, IND
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19
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A study of critically ill children presenting with seizures regardless of seizure duration admitted in the PICU of a tertiary hospital in India. Epilepsy Behav Rep 2020; 14:100382. [PMID: 32995739 PMCID: PMC7516043 DOI: 10.1016/j.ebr.2020.100382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/18/2020] [Accepted: 07/22/2020] [Indexed: 12/03/2022] Open
Abstract
Our aim was to study the clinical profile, immediate outcome and risk factors associated with poor outcome in critically ill children presenting with seizures requiring PICU admission. As seizures lasting 10 min or more can potentially cause brain damage, we included all children regardless of seizure duration. The records of 157 children aged 1 month to 16 years admitted in the PICU at a tertiary hospital in India with seizures as the presenting symptom during a three-year period were studied retrospectively. Median age of patients was 4 years. 34 (21%) had pre-existing epilepsy and 33 (21%) had previous developmental delay/neuro-deficit. Seizure duration was > 30 min in 75 (47.7%) and 56 (35.6%) required the use of more than 2 antiseizure drugs. 101 (64%) had acute symptomatic seizures, 28 (17%) remote symptomatic and 27 (17.1%) had unknown cause. New onset neurological deficit was seen in 18 (15.6%) and 14 (8.9%) died. Young age, high PEWS score at presentation, prolonged/recurrent seizures, CNS infection, need for multiple antiseizure drugs and ventilation/pressor use were risk factors for poor outcome. Neurological outcome and survival of children in our study were good. Further all-inclusive studies irrespective of seizure duration are needed to obtain a complete picture of critical children presenting with seizures. All critical children presenting with seizures were included irrespective of seizure duration 52.2% patients had seizures lasting for less than 30 min 28.6% patients had CNS infection as the underlying etiology Short-term neurological outcome was comparable to previous reports Mortality associated with status epilepticus was lower than that reported by other Indian studies
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20
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Wagner RG, Kabudula CW, Forsgren L, Ibinda F, Lindholm L, Kahn K, Tollman S, Newton CR. Epilepsy care cascade, treatment gap and its determinants in rural South Africa. Seizure 2020; 80:175-180. [PMID: 32593141 PMCID: PMC7443697 DOI: 10.1016/j.seizure.2020.06.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/14/2020] [Accepted: 06/06/2020] [Indexed: 12/20/2022] Open
Abstract
Most people with active convulsive epilepsy in rural South Africa are diagnosed. Most individuals diagnosed have some blood level of anti-seizure medication. Most individuals do not have optimal levels of medication. The epilepsy treatment gap is high in rural South Africa, especially in children. Identifying the epilepsy care cascade may better allow for targeting of interventions.
Purpose The percentage of people who are diagnosed with epilepsy (diagnostic gap), access, receive and adhere (treatment gap) to anti-seizure medication (ASM) in low- and middle- income countries remains low. We explored the epilepsy care cascade, measured the diagnostic and treatment gaps, and examined socio-demographic factors associated with adherence to ASMs in rural South Africa. Methods Utilizing a population-based cohort of 311 people with active convulsive epilepsy (ACE) residing in rural northeastern South Africa, a questionnaire was administered to examine associations between demographic and socioeconomic factors and the epilepsy treatment gap. Blood was taken to measure levels of ASMs. Results Of the 311 individuals diagnosed, 93 % of individuals reported being previously told they had epilepsy and 94 % reported previously attending a health facility for their epilepsy. ASMs were detected in 138 individuals (76 %) and optimal levels were detected in 67 individuals, resulting in a treatment gap of 63 % (95 % confidence interval [95 %CI]: 56 %–70 %). Self-reported specificity of ASM use was 23 % (95 %CI: 12–39 %) and individuals ≥18 years were significantly more likely to report taking ASM than children and were significantly (p = 0.011) more likely to be adherent. Conclusion Most people with epilepsy in rural South Africa had been previously diagnosed with epilepsy and had accessed care for epilepsy, yet the level of ASM adherence remained low, significantly lower amongst children. Understanding ways of improving knowledge of and adherence to ASM in rural South Africa is necessary, especially amongst children. The epilepsy care cascade can be useful in identifying gaps in care and targeting interventions to reduce these gaps.
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Affiliation(s)
- Ryan G Wagner
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS) - INDEPTH Network, Accra, Ghana; MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden; Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden.
| | - Chodziwadziwa W Kabudula
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lars Forsgren
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Fredrick Ibinda
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, Kilifi, Kenya
| | - Lars Lindholm
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Kathleen Kahn
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden; INDEPTH Network, Accra, Ghana
| | - Stephen Tollman
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden; INDEPTH Network, Accra, Ghana
| | - Charles R Newton
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS) - INDEPTH Network, Accra, Ghana; MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, Kilifi, Kenya; Neurosciences Unit, UCL Institute of Child Health, London, United Kingdom; Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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Arya A, Azad C, Mahajan V, Guglani V. Convulsive Status Epilepticus in Children: A Prospective Observational Study from India. JOURNAL OF PEDIATRIC EPILEPSY 2020. [DOI: 10.1055/s-0040-1712544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractConvulsive status epilepticus (CSE) is one of the commonest and life threatening pediatric neurological emergencies. Only few studies on pediatric status epilepticus (SE) are available from the Indian subcontinent. The aim was to study the etiology and immediate outcome of CSE in children getting admitted in pediatric emergency during the study period and to study association of various clinical presentations with immediate outcome. A prospective observational study was conducted in tertiary care institute of Northern India. Children aged between 1 month and 18 years with CSE were enrolled and followed up till discharge. Primary outcome was kept as hospital survival/mortality; those who survived were further graded on the basis of disability at discharge. A total of 81 patients with CSE were assessed for primary outcome. The mortality rate was found to be 15% (12/81); 83% deaths were due to acute central nervous system (CNS) infection. Ten percent of children (8/81) had disability at discharge, five had mild, and three had moderate disability. The neurocysticercosis was the most common etiology seen in 23% (19/81) of the children followed by febrile SE in 20% (13/81) of the study participants. CSE responded to first-line antiepileptic drugs (AED) in 15% children (12/81). Refractory status was seen in 13.5% (11/81) cases. Prehospital treatment was received only in 15% patients. Young age, low Glasgow coma scale score at admission, and requirement of critical care support were the factors found to be significantly associated with mortality. CSE has a high mortality especially in young children and acute CNS infections are the most common cause of it.
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Affiliation(s)
- Adhi Arya
- Department of Pediatric Cardiology, Fortis Escorts Heart Institute, New Delhi, India
| | - Chandrika Azad
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Vidushi Mahajan
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Vishal Guglani
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
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Chetan C, Sharma S, Mathur SB, Jain P, Aneja S. Clinical Profile and Short-term Outcome of Pediatric Status Epilepticus at a Tertiary-care Center in Northern India. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1753-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Leitinger M, Trinka E, Zimmermann G, Granbichler CA, Kobulashvili T, Siebert U. Epidemiology of status epilepticus in adults: Apples, pears, and oranges - A critical review. Epilepsy Behav 2020; 103:106720. [PMID: 31902646 DOI: 10.1016/j.yebeh.2019.106720] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 11/02/2019] [Accepted: 11/13/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Status epilepticus (SE) is a severe neurologic condition associated with high morbidity and mortality. Population-based studies in adults have found a wide range of incidences in various regions in the world. Although the incidence of SE increases almost exponentially in the elderly, data on census-based population statistics in these studies are scarce. This study provides a critical review with an emphasis on census-based population statistics and study characteristics in adults. METHODS We performed a systematic search of population-based studies on SE in adults in PubMed using "status epilepticus" in combination with "epidemiology", "population", and "incidence" as search terms, and also screened references. For each identified study, we assessed and extracted the respective population pyramids of study and reference population, and study characteristics. RESULTS We identified 22 population-based studies (eleven from Europe, six from North America, three from Asia, one from Africa, and one from Australasia). Incidence rates of patients with SE ranged from 1.29 to 73.7/100,000 adults (95% confidence interval (CI): 76.6-80.3) and of SE episodes up to 81.1/100,000 adults (95% CI: 75.8-87.0). The proportions of elderly and very old patients varied by a factor of 2.6 and 8.5, respectively, depending on study period and place. Further major reasons for heterogeneity were retrospective or prospective study design, definition of time to diagnose SE, variable detection of nonconvulsive SE (NCSE), different etiologies, inclusion of children, recurrent episodes, postanoxic patients, exclusion of patients with preexisting epilepsy or patients identified outside the emergency department, and choice of reference population for age- and gender adjustment. The most recent definition and classification of SE by the International League Against Epilepsy (ILAE) 2015 was used in two studies. Four studies (18.2%) reported incidences per ten-year age strata necessary for age adjustment to various reference populations. CONCLUSIONS This critical review reveals a marked heterogeneity among population-based studies on SE in adults. It provides comprehensive details on census-based population statistics in study and reference populations and various study designs and characteristics essential for direct comparisons between studies. Reporting on these essential key features should be improved in population-based studies on SE.
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Affiliation(s)
- Markus Leitinger
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University Salzburg, Austria; Centre of Neuroscience, Christian Doppler University Hospital, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University Salzburg, Austria; Centre of Neuroscience, Christian Doppler University Hospital, Salzburg, Austria; Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics nd Technology, Hall in Tirol, Austria
| | - Georg Zimmermann
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University Salzburg, Austria; Department of Mathematics, Paris-Lodron-University of Salzburg, Salzburg, Austria
| | - Claudia A Granbichler
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University Salzburg, Austria; Sheba Medical Center, Department of Neurology, Tel Hashomer, Israel
| | - Teia Kobulashvili
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University Salzburg, Austria; Centre of Neuroscience, Christian Doppler University Hospital, Salzburg, Austria
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics nd Technology, Hall in Tirol, Austria; Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Farmania R, Garg D, Sharma S. Status Epilepticus in Neonates and Infants. Ann Indian Acad Neurol 2020; 23:747-754. [PMID: 33688122 PMCID: PMC7900746 DOI: 10.4103/aian.aian_189_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/01/2020] [Accepted: 04/08/2020] [Indexed: 11/13/2022] Open
Abstract
Status epilepticus (SE) is a common neurological emergency in childhood associated with high mortality and morbidity. Acute management of seizures along with aggressive evaluation for establishing the underlying cause are crucial determinants of outcome. Neonatal status epilepticus carries the burden of poor neurological outcomes and may lead to global developmental delay as well as persistent seizures. The aetiology and pathophysiological mechanisms of SE in neonates and young infants differ compared to older children and adults. The most common causes of SE in neonates includes hypoxic sequelae, ischemic stroke and intracranial haemorrhage. In infants, febrile status epilepticus and acute symptomatic seizures are more common than remote symptomatic causes. Recent advances in neuroimaging modalities and molecular diagnostic techniques have facilitated better diagnostic precision. There is deplorable lack of evidence evaluating management strategies of SE in this age group. In addition to prompt initiation of antiseizure medications, vitamin supplementation needs to be empirically added. Simultaneously, meticulous evaluation to determine cause must also be conducted. In this review, we discuss challenges and an algorithmic approach to the diagnosis and management of SE in neonates and infants.
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Affiliation(s)
- Rajni Farmania
- Paediatric Neurologist, BL Kapoor Hospital, New Delhi, India
| | - Divyani Garg
- Department of Neurology, Lady Hardinge Medical College, New Delhi, India
| | - Suvasini Sharma
- Paediatrics, Lady Hardinge Medical College, New Delhi, India,Address for correspondence: Dr. Suvasini Sharma, Associate Professor, Department of Paediatrics (Neurology Division), Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi - 110 001, India. E-mail:
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Sirikarn P, Pattanittum P, Sawanyawisuth K, Tiamkao S. Causes of death in patients with status epilepticus. Epilepsy Behav 2019; 101:106372. [PMID: 31300380 DOI: 10.1016/j.yebeh.2019.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/11/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Status epilepticus (SE) is a neurological disorder that affects to the high mortality risk. Several studies reported predictors of mortality in SE; actual causes of death in hospital and out of hospital are limited. This study aimed to describe the case fatality and the causes of death in patients with SE. METHODS This was a descriptive study using the data collected in the national data of the Universal Coverage Scheme in Thailand during the fiscal year 2005 to 2015. Patients who admitted to hospitals and diagnosed as SE were included. The vital status of patients with SE was linked with the Ministry of the Interior and was classified into three phases: in-hospital, short-term, and long-term. RESULTS Among 24,802 patients with SE, 1861 (7.5%) died in hospital, 1910 (7.7%) died within 30 days after hospital discharge, and 4906 (19.8%) died after 30 days. In-hospital death, SE complications (45.9%), seizure (19.6%), and comorbidities (15.4%) were the three common causes of death. While the common causes in short-term and long-term mortality were SE complications (27.7% and 31.0%), comorbidities (28.1% and 26.7%), and other causes (22.4% and 21.9%). CONCLUSION Status epilepticus complications and comorbidities were the common cause of death in patients with SE for all of three periods. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Affiliation(s)
- Prapassara Sirikarn
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand; Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand.
| | - Porjai Pattanittum
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.
| | - Kittisak Sawanyawisuth
- Division of Neurology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Sleep Apnea Research Group, Research Center in Back, Neck and Other Joint Pain and Human Performance, Research and Training Center for Enhancing Quality of Life of Working Age People, and Research and Diagnostic Center for Emerging Infectious Diseases (RCEID), Khon Kaen University, Khon Kaen, Thailand.
| | - Somsak Tiamkao
- Division of Neurology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand.
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Chin RFM. The outcomes of childhood convulsive status epilepticus. Epilepsy Behav 2019; 101:106286. [PMID: 31196823 DOI: 10.1016/j.yebeh.2019.04.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/19/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Few studies focus specifically on childhood convulsive status epilepticus (CSE). Geographical differences and study design may influence research findings. A comprehensive understanding of the outcomes of childhood CSE needs to bear these factors in mind when examining the published literature. A systematic review of the outcome of childhood CSE was carried out more than a decade ago. Since then, there have been major prospective studies (in the United Kingdom, the United States of America, and in sub-Saharan Africa (SSA)) focused on childhood CSE. METHODS Six major prospective studies are described, and their results combined through a narrative synthesis with findings of the earlier systematic review. The following CSE outcomes are described: (1) recurrence; (2) short-term mortality; (3) subsequent epilepsy; (4) neurological, cognitive, and behavioral impairments outside of epilepsy; (5) long-term mortality; (6) association with hippocampal injury and mesial temporal sclerosis (MTS); and (7) white matter changes. RESULTS One-year recurrence after the first-ever CSE, whether its prolonged febrile seizures (PFS) or non-PFS, is 16% (95% confidence interval [CI]: 10-24). Twenty percent will have a recurrence within 4 years. Case fatality during hospitalization in high income countries is 2.7-5.2%, and 15% in SSA. The cumulative incidence of subsequent epilepsy nine years post-CSE is 25% (95% CI: 16-36). Neurological, cognitive, and behavioral impairments outside of epilepsy are detectable within 6 weeks of CSE. This persists at one year, and by 9 years follow-up, at least at third of subjects will be affected. Long-term mortality ranges from 5 to 17%, with the true estimate at 9 years follow-up to be 8% with standardized mortality ratio of 46. Mesial temporal sclerosis is uncommon, and decreased hippocampal volume is seen in both PFS and non-PFS. Duration is not but etiology/CSE type is, associated with outcome. CONCLUSION Childhood CSE is associated with substantial morbidity and mortality. Etiology but not duration is the main determinant. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures.
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Affiliation(s)
- Richard F M Chin
- Muir Maxwell Epilepsy Centre, University of Edinburgh, Edinburgh, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK; Paediatric Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK.
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Samia P, Hassell J, Hudson JA, Murithi MK, Kariuki SM, Newton CR, Wilmshurst JM. Epilepsy diagnosis and management of children in Kenya: review of current literature. Res Rep Trop Med 2019; 10:91-102. [PMID: 31388319 PMCID: PMC6607977 DOI: 10.2147/rrtm.s201159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/12/2019] [Indexed: 01/04/2023] Open
Abstract
Introduction: The growing impact of non-communicable diseases in low- to middle-income countries makes epilepsy a key research priority. We evaluated peer-reviewed published literature on childhood epilepsy specific to Kenya to identify knowledge gaps and inform future priorities. Methodology: A literature search utilizing the terms “epilepsy” OR “seizure” as exploded subject headings AND “Kenya” was conducted. Relevant databases were searched, generating 908 articles. After initial screening to remove duplications, irrelevant articles, and publications older than 15 years, 154 papers remained for full-article review, which identified 35 publications containing relevant information. Data were extracted from these reports on epidemiology, etiology, clinical features, management, and outcomes. Results: The estimated prevalence of lifetime epilepsy in children was 21–41 per 1,000, while the incidence of active convulsive epilepsy was 39–187 cases per 100,000 children per year. The incidence of acute seizures was 312–879 per 100,000 children per year and neonatal seizures 3,950 per 100,000 live births per year. Common risk factors for both epilepsy and acute seizures included adverse perinatal events, meningitis, malaria, febrile seizures, and family history of epilepsy. Electroencephalography abnormalities were documented in 20%–41% and neurocognitive comorbidities in more than half. Mortality in children admitted with acute seizures was 3%–6%, and neurological sequelae were identified in 31% following convulsive status epilepticus. Only 7%–29% children with epilepsy were on antiseizure medication. Conclusion: Active convulsive epilepsy is a common condition among Kenyan children, remains largely untreated, and leads to extremely poor outcomes. The high proportion of epilepsy attributable to preventable causes, in particular neonatal morbidity, contributes significantly to the lifetime burden of the condition. This review reaffirms the ongoing need for better public awareness of epilepsy as a treatable disease and for national-level action that targets both prevention and management.
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Affiliation(s)
- Pauline Samia
- Department of Paediatrics and Child Health, Aga Khan University, Nairobi, Kenya
| | - Jane Hassell
- Gertrude's Children's Hospital, Child development Centre, Nairobi, Kenya
| | | | | | - Symon M Kariuki
- Kemri-Wellcome Trust Collaborative Programme, Centre for Geographic Medicine Research Programme, Kilifi, Kenya
| | - Charles R Newton
- Kemri-Wellcome Trust Collaborative Programme, Centre for Geographic Medicine Research Programme, Kilifi, Kenya
| | - Jo M Wilmshurst
- Division of Paediatric Neurology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Rondebosch, South Africa
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Burman RJ, Ackermann S, Shapson-Coe A, Ndondo A, Buys H, Wilmshurst JM. A Comparison of Parenteral Phenobarbital vs. Parenteral Phenytoin as Second-Line Management for Pediatric Convulsive Status Epilepticus in a Resource-Limited Setting. Front Neurol 2019; 10:506. [PMID: 31156538 PMCID: PMC6530138 DOI: 10.3389/fneur.2019.00506] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/26/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction: Pediatric convulsive status epilepticus (CSE) which is refractory to first-line benzodiazepines is a significant clinical challenge, especially within resource-limited countries. Parenteral phenobarbital is widely used in Africa as second-line agent for pediatric CSE, however evidence to support its use is limited. Purpose: This study aimed to compare the use of parenteral phenobarbital against parenteral phenytoin as a second-line agent in the management of pediatric CSE. Methodology: An open-labeled single-center randomized parallel clinical trial was undertaken which included all children (between ages of 1 month and 15 years) who presented with CSE. Children were allocated to receive either parenteral phenobarbital or parenteral phenytoin if they did not respond to first-line benzodiazepines. An intention-to-treat analysis was performed with the investigators blinded to the treatment arms. The primary outcome measure was the success of terminating CSE. Secondary outcomes included the need for admission to the pediatric intensive care unit (PICU) and breakthrough seizures during the admission. In addition, local epidemiological data was collected on the burden of pediatric CSE. Results: Between 2015 and 2018, 193 episodes of CSE from 111 children were enrolled in the study of which 144 met the study requirements. Forty-two percent had a prior history of epilepsy mostly from structural brain pathology (53%). The most common presentation was generalized CSE (65%) caused by acute injuries or infections of the central nervous system (59%), with 19% of children having febrile status epilepticus. Thirty-five percent of children required second-line management. More patients who received parenteral phenobarbital were at a significantly reduced risk of failing second-line treatment compared to those who received parenteral phenytoin (RR = 0.3, p = 0.0003). Phenobarbital also terminated refractory CSE faster (p < 0.0001). Furthermore, patients who received parenteral phenobarbital were less likely to need admission to the PICU. There was no difference between the two groups in the number of breakthrough seizures that occurred during admission. Conclusion: Overall this study supports anecdotal evidence that phenobarbital is a safe and effective second-line treatment for the management of pediatric CSE. These results advocate for parenteral phenobarbital to remain available to health care providers managing pediatric CSE in resource-limited settings. Attachments: CONSORT 2010 checklist Trial registration: NCT03650270 Full trial protocol available: https://clinicaltrials.gov/ct2/show/NCT03650270?recrs=e&type=Intr&cond=Status+Epilepticus&age=0&rank=1.
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Affiliation(s)
- Richard J Burman
- Division of Paediatric Neurology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Faculty of Health Sciences, University of Cape Town Neuroscience Institute, Cape Town, South Africa
| | - Sally Ackermann
- Division of Paediatric Neurology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Alexander Shapson-Coe
- Division of Paediatric Neurology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Alvin Ndondo
- Division of Paediatric Neurology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Faculty of Health Sciences, University of Cape Town Neuroscience Institute, Cape Town, South Africa
| | - Heloise Buys
- Ambulatory and Emergency Services, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Jo M Wilmshurst
- Division of Paediatric Neurology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Faculty of Health Sciences, University of Cape Town Neuroscience Institute, Cape Town, South Africa
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Dibué-Adjei M, Brigo F, Yamamoto T, Vonck K, Trinka E. Vagus nerve stimulation in refractory and super-refractory status epilepticus - A systematic review. Brain Stimul 2019; 12:1101-1110. [PMID: 31126871 DOI: 10.1016/j.brs.2019.05.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/06/2019] [Accepted: 05/08/2019] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Refractory status epilepticus (RSE) is the persistence of status epilepticus despite second-line treatment. Super-refractory SE (SRSE) is characterized by ongoing status despite 48 h of anaesthetic treatment. Due to the high case fatality in RSE of 16-39%, off label treatments without strong evidence of efficacy in RSE are often administered. In single case-reports and small case series totalling 28 patients, acute implantation of VNS in RSE was associated with 76% and 26% success rate in generalized and focal RSE respectively. We performed an updated systematic review of the literature on efficacy of VNS in RSE/SRSE by including all reported patients. METHODS We systematically searched EMBASE, CENTRAL, Opengre.eu, and ClinicalTrials.gov, and PubMed databases to identify studies reporting the use of VNS for RSE and/or SRSE. We also searched conference abstracts from AES and ILAE meetings. RESULTS 45 patients were identified in total of which 38 were acute implantations of VNS in RSE/SRSE. Five cases had VNS implantation for epilepsia partialis continua, one for refractory electrical status epilepticus in sleep and one for acute encephalitis with refractory repetitive focal seizures. Acute VNS implantation was associated with cessation of RSE/SRSE in 74% (28/38) of acute cases. Cessation did not occur in 18% (7/38) of cases and four deaths were reported (11%); all of them due to the underlying disease and unlikely related to VNS implantation. Median duration of the RSE/SRSE episode pre and post VNS implantation was 18 days (range: 3-1680 days) and 8 days (range: 3-84 days) respectively. Positive outcomes occurred in 82% (31/38) of cases. CONCLUSION VNS can interrupt RSE and SRSE in 74% of patients; data originate from reported studies classified as level IV and the risk for reporting bias is high. Further prospective studies are warranted to investigate acute VNS in RSE and SRSE.
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Affiliation(s)
- Maxine Dibué-Adjei
- LivaNova Deutschland GmbH, LivaNova PLC-owned Subsidiary, Lindberghstraße 25, 80939, Munich, Germany; Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, D-40225, Düsseldorf, Germany.
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Takamichi Yamamoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Kristl Vonck
- Brain Research Team, Department of Neurology, Ghent University, Ghent, Belgium
| | - Eugen Trinka
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Salzburg, Austria; Institute of Public Health, Medical Decision Making and HTA, UMIT, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria
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Jafarpour S, Stredny CM, Piantino J, Chapman KE. Baseline and outcome assessment in pediatric status epilepticus. Seizure 2019; 68:52-61. [DOI: 10.1016/j.seizure.2018.04.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/21/2018] [Accepted: 04/24/2018] [Indexed: 11/29/2022] Open
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Lee B. Treatment gap for convulsive status epilepticus in resource-poor countries. Epilepsia 2018; 59 Suppl 2:135-139. [PMID: 30175402 DOI: 10.1111/epi.14484] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2017] [Indexed: 11/28/2022]
Abstract
The magnitude of the treatment gap (TG) for convulsive status epilepticus (CSE) in resource-poor countries is unknown. Hospital-based cohort studies from developing countries revealed that the management of CSE was usually suboptimal due to lack of advanced diagnostic and treatment facilities, significant delay in patient's presentation at hospital, and shortages of essential antiepileptic drugs (AEDs). However, there were no significant differences in the proportion of refractory status epilepticus, short-term mortalities, and morbidities of CSE between the developed and the developing countries. Therefore, the presence of significant TG for CSE in developing countries is still an assumption without evidence. We conducted an expert survey in Asia for potential sources of TG. Experts from 16 Asian countries responded to the questionnaire. An injectable form of diazepam was available in all 16 countries even at the primary care level, but intravenous lorazepam was available only in four countries. Second-line AEDs were widely available at tertiary care hospitals, but not at primary care hospitals. Lack of second-line AEDs at primary care hospitals, significant delay in patient transportation to the hospital, shortages of intensive care unit facilities, and absence of trained physicians were important contributing factors to TG in Asia.
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Affiliation(s)
- Byungin Lee
- Department of Neurology, Epilepsy Center, Inje University School of Medicine, Haeundae Paik Hospital, Busan, Korea
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Jafarpour S, Hodgeman RM, De Marchi Capeletto C, de Lima MTA, Kapur K, Tasker RC, Loddenkemper T. New-Onset Status Epilepticus in Pediatric Patients: Causes, Characteristics, and Outcomes. Pediatr Neurol 2018; 80:61-69. [PMID: 29373157 DOI: 10.1016/j.pediatrneurol.2017.11.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 11/20/2017] [Accepted: 11/26/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Many pediatric patients presenting with status epilepticus have no history of seizures. METHODS We retrospectively analyzed the clinical characteristics of patients aged one month to 21 years who presented during six consecutive years with convulsive status epilepticus and without a history of seizures. New-onset refractory status epilepticus was defined as status epilepticus refractory to two lines of treatment, without an identified cause in the first 48 hours. RESULTS Of 460 patients with status epilepticus, 79 (17.2%) presented with new-onset status epilepticus, including four (0.9%) with new-onset refractory status epilepticus. Of those patients, 54.4% were female, and the median age was 3.5 years (IQR: 1.08 to 6.75). The median seizure duration was 20 minutes (IQR: 10 to 40 minutes). Etiology was unknown in 36.7%, symptomatic in 30.3%, provoked in 16.5%, and provoked with an existing symptomatic etiology in 16.5%. Patients were followed for a median duration of 63 months (IQR: 21 to 97). The mortality rate was 3.8%. Of 55 patients who were developmentally normal at baseline, 29.1% had a significant cognitive impairment at the last follow-up, and 20% had academic difficulties or behavioral problems. Patients with symptomatic etiology had greater odds of having cognitive and behavioral problems compared with patients with unknown etiology (odds ratio = 3.83, P = 0.012). CONCLUSIONS Patients with new-onset status epilepticus are at risk for recurrent seizures, recurrent status epilepticus, death, and subsequent cognitive-behavioral impairment. Specific monitoring and care interventions might be required in this high-risk population.
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Affiliation(s)
- Saba Jafarpour
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ryan M Hodgeman
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Michigan State University College of Osteopathic Medicine East Lansing, MI
| | - Carolina De Marchi Capeletto
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Medical School, Faculdade Evangélica do Paraná, Curitiba, Brazil
| | - Mateus Torres Avelar de Lima
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Faculty of Medicine, Universidade de Brasilia, Brasilia, Brazil
| | - Kush Kapur
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert C Tasker
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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Pujar SS, Martinos MM, Cortina-Borja M, Chong WKK, De Haan M, Gillberg C, Neville BG, Scott RC, Chin RF. Long-term prognosis after childhood convulsive status epilepticus: a prospective cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:103-111. [DOI: 10.1016/s2352-4642(17)30174-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 10/25/2017] [Accepted: 11/01/2017] [Indexed: 12/20/2022]
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Li XC, Lu LL, Wang JZ, Wang M, Gao Y, Lin YX, Han ZH. Clinical characteristics and electroencephalogram analysis of levetiracetam in the treatment of children with febrile seizure recurrence. Exp Ther Med 2017; 14:2015-2020. [PMID: 28962118 PMCID: PMC5609163 DOI: 10.3892/etm.2017.4738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 05/11/2017] [Indexed: 11/05/2022] Open
Abstract
Febrile seizure is the most common neurologic disorder in infants and children. This study aimed to elaborate safe and effective therapy for preventing FS recurrence by levetiracetam (LEV). A prospective study was performed in two groups of children, the no treatment group (n=51, 24.1±9.0 months) and the LEV treatment group (n=45, 23.3±8.9 months). The findings demonstrated that a significant difference (P<0.01) was observed between the no treatment group 51.0% (26/51) and LEV treatment group 15.5% (7/45) in terms of FS recurrence after 50 weeks. FS recurrence/fever episode was 12.4% (12/97) in the LEV treatment group and 51.8% (57/110) in the no treatment group. Furthermore, LEV administration significantly improved (P<0.001) epileptiform + nonspecific EEG abnormalities (17.8%; 8/45), as compared with the no treatment group (68.6%; 35/51). In conclusion, LEV could function as an effective therapeutic agent for the prevention of FS recurrence and reducing the frequency of fever episodes. Furthermore, LEV administration significantly improved nonspecific EEG abnormalities, which may be used as a clinical monitoring index for LEV treatment in patients with FS.
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Affiliation(s)
- Xue-Chao Li
- Department of Pediatrics, Maternal and Child Care Center of Qinhuangdao, Qinhuangdao, Hebei 066000, P.R. China
| | - Ling-Ling Lu
- Centers for Disease Control and Prevention of Qinhuangdao, Qinhuangdao, Hebei 066009, P.R. China
| | - Jian-Zhong Wang
- Department of Pediatrics, Maternal and Child Care Center of Qinhuangdao, Qinhuangdao, Hebei 066000, P.R. China
| | - Miao Wang
- Department of Pediatrics, Maternal and Child Care Center of Qinhuangdao, Qinhuangdao, Hebei 066000, P.R. China
| | - Yu Gao
- Department of Pediatrics, Maternal and Child Care Center of Qinhuangdao, Qinhuangdao, Hebei 066000, P.R. China
| | - Ye-Xin Lin
- Department of Children ICU, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110004, P.R. China
| | - Zhong-Hou Han
- Department of Pediatrics, Maternal and Child Care Center of Qinhuangdao, Qinhuangdao, Hebei 066000, P.R. China
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Kind CJ, Newton CRJC, Kariuki SM. Prevalence, risk factors, and neurobehavioral comorbidities of epilepsy in Kenyan children. Epilepsia Open 2017; 2:388-399. [PMID: 29588970 PMCID: PMC5862110 DOI: 10.1002/epi4.12069] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2017] [Indexed: 12/25/2022] Open
Abstract
Objective To investigate the prevalence, risk factors, clinical features, and neurobehavioral comorbidities of epilepsy and acute symptomatic seizures in school‐aged children in Kilifi, Kenya. Methods Randomly selected children (N = 11,223) were screened for epilepsy and other neurodevelopmental disorders. Those who screened positive were invited for further clinical, electroencephalographic (EEG), and neuropsychological evaluations. Prevalence was measured by dividing cases by screened population, providing Agresti–Coull confidence intervals (CIs). Prevalence ratios were computed using log binomial regression, and odds ratios (ORs) were computed using logistic regression; both were implemented with generalized linear models. Attention‐deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and other neurodevelopmental impairments were assessed in cases and controls. Results Prevalence of lifetime epilepsy was 20.9 per 1,000 (95% CI = 18.4–23.7), and that of active epilepsy was 11.5 per 1,000 (95% CI = 9.7–13.6). Prevalence of acute symptomatic seizures was 68.8 per 1,000 (95% CI = 64.2–73.6). Acute symptomatic seizures preceded a diagnosis of epilepsy in 8% of children. Of 98 children diagnosed with epilepsy, focal seizures were seen in 79%, abnormal EEG was seen in 39%, and 83% were not receiving antiepileptic drugs. Childhood absence epilepsy and Lennox–Gastaut epilepsy were the most easily identifiable epilepsy syndromes. Perinatal complications, previous hospitalization, geophagia, and snoring were risk factors for epilepsy. Family history of seizures, abnormal pregnancy, previous hospitalization, and snoring were risk factors for acute symptomatic seizures. Neurobehavioral comorbidities were present in 54% of subjects with lifetime epilepsy and in 3% of controls, with associations for individual comorbidities being statistically significant: ADHD (OR = 14.55, 95% CI = 7.54–28.06), ASD (OR = 36.83, 95% CI = 7.97–170.14), and cognitive impairments (OR = 14.55, 95% CI = 3.52–60.14). Significance The burden of seizure disorders in this area is higher than in locations in high‐income countries, and can be reduced by preventing risk factors. A comprehensive management plan for neurobehavioral comorbidities of epilepsy should be incorporated into standard epilepsy care.
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Affiliation(s)
- Charles J Kind
- St. Johns College University of Oxford Oxford United Kingdom
| | - Charles R J C Newton
- St. Johns College University of Oxford Oxford United Kingdom.,KEMRI-Wellcome Trust Research Programme Kilifi Kenya.,Department of Psychiatry University of Oxford Oxford United Kingdom
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Reddy Y, Balakrishna Y, Mubaiwa L. Convulsive status epilepticus in a quaternary hospital paediatric intensive care unit (PICU) in South Africa: An 8 year review. Seizure 2017; 51:55-60. [PMID: 28886496 DOI: 10.1016/j.seizure.2017.07.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 06/29/2017] [Accepted: 07/28/2017] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Convulsive status epilepticus (CSE) is associated with a high morbidity and mortality. This study aimed to describe the clinical profile, aetiology, neuroimaging and EEG findings as well as outcome of children with CSE in Sub-Saharan Africa. METHODS This was a retrospective analysis of electronic records of children with CSE admitted to the Paediatric Intensive Care Unit (PICU) over an 8-year period from January 2007 to December 2014. RESULTS Seventy six patients were admitted to the PICU with CSE and 55(72%) had refractory status epilepticus. The median age at presentation was 15 months (IQR 6-37 months). The main aetiologies were meningoencephalitis and gastroenteritis in 33(43%) and 19(25%) patients respectively. The most frequently used antiepileptic drugs for CSE in PICU consisted of infusions of midazolam (96%) and thiopentone (22%). Neuroimaging findings were abnormal in 53(75%) patients with hypoxic changes in 17 patients. On multivariable regression, the predictors of poor outcome included the use of more than 3 antiepileptic drugs in PICU(RR-1.41(1.12-1.78), p=0.003), duration of mechanical ventilation for more than 3days (RR 1.98(1.22-3.20), p=0.005) and abnormal neuroimaging findings (RR 3.21(1.53-6.72), p=0.002). The mortality rate was 24%(n=18). Persistent seizures or a new neurological deficit occurred in 58%(n=44). The main cause of mortality was CSE related diffuse cortical and brainstem injury. Predominant neurological sequelae were cerebral palsy and persistent epilepsy. CONCLUSION The high burden of infection related CSE is associated with high morbidity and mortality rates in contrast to the rates in developed countries. This highlights the need for early recognition and treatment of underlying conditions.
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Affiliation(s)
- Yavini Reddy
- Department of Paediatric Neurology, University of KwaZulu-Natal, Durban, South Africa.
| | - Yusentha Balakrishna
- Biostatistics Unit, South African Medical Research Council, Durban, South Africa
| | - Lawrence Mubaiwa
- Department of Paediatric Neurology, University of KwaZulu-Natal, Durban, South Africa
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Abstract
OBJECTIVES Because meningitis may trigger seizures, we sought to determine its frequency in children with first-time status epilepticus (SE). METHODS We performed a retrospective cross-sectional study of children aged 1 month to 21 years who presented to a single pediatric emergency department between 1995 and 2012 with SE and who had a lumbar puncture (LP) performed as part of the diagnostic evaluation. We defined bacterial meningitis as a cerebrospinal fluid (CSF) culture positive for a bacterial pathogen or CSF pleocytosis (CSF white blood cells ≥10 cells/mm) with a blood culture positive for a bacterial pathogen. We defined viral meningitis or encephalitis using a positive enterovirus or herpes simplex virus polymerase chain reaction test. RESULTS Among 126 children with SE who had an LP performed, 8 (6%) had CSF pleocytosis. Of these, 5 had received antibiotics before performance of a diagnostic LP. One child in the cohort was proven to have bacterial meningitis (0.8%; 95% confidence interval [CI], 0%-6%). Two other children had enteroviral meningitis (2/13 tested, 15%; 95% CI, 3%-51%), and 1 had a herpes simplex virus infection (1/47, 2%; 95% CI, 0%-15%). CONCLUSIONS Bacterial meningitis is an uncommon cause of SE.
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Lv RJ, Wang Q, Cui T, Zhu F, Shao XQ. Status epilepticus-related etiology, incidence and mortality: A meta-analysis. Epilepsy Res 2017; 136:12-17. [PMID: 28734267 DOI: 10.1016/j.eplepsyres.2017.07.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/11/2017] [Accepted: 07/02/2017] [Indexed: 10/19/2022]
Abstract
Status epilepticus (SE) is a severe medical condition. To determine its epidemiology and outcome of SE, we performed a meta-analysis to investigate the etiology, incidence and mortality of SE. We searched PubMed and Embase between Jan 1, 2000, and Oct 31, 2016, with no regional restrictions, for observational studies of the etiology, incidence and mortality of SE. Forty-three studies were included in the meta-analysis. The pooled crude annual incidence rate, the pooled case fatality rate and the pooled crude annual mortality rate of SE were 12.6/100,000 (95% CI: 10.0-15.3), 14.9% (95% CI: 11.7-118.7) and 0.98/100,000 (95% CI: 0.74-1.22), respectively. Elderly subjects with SE had a higher case fatality rate (28.4% (95% CI: 17.7-42.3)) and crude annual incidence rate (27.1% (95% CI: 15.8-38.2)). The most important etiology-specific attributable fraction of patients with SE was acute symptomatic etiology (OR 0.411, 95% CI: 0.315-0.507). Age and economic income contributed to differences in SE incidence and short-term case fatality rate.
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Affiliation(s)
- Rui-Juan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China; China National Clinical Research Center for Neurological Diseases, Beijing, PR. China, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China; China National Clinical Research Center for Neurological Diseases, Beijing, PR. China, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China
| | - Tao Cui
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China; China National Clinical Research Center for Neurological Diseases, Beijing, PR. China, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China
| | - Fei Zhu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China; China National Clinical Research Center for Neurological Diseases, Beijing, PR. China, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China
| | - Xiao-Qiu Shao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China; China National Clinical Research Center for Neurological Diseases, Beijing, PR. China, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China.
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Akhuemokhan OC, Ewah-Odiase RO, Akpede N, Ehimuan J, Adomeh DI, Odia I, Olomu SC, Pahlmann M, Becker-Ziaja B, Happi CT, Asogun DA, Okogbenin SA, Okokhere PO, Dawodu OS, Omoike IU, Sabeti PC, Günther S, Akpede GO. Prevalence of Lassa Virus Disease (LVD) in Nigerian children with fever or fever and convulsions in an endemic area. PLoS Negl Trop Dis 2017; 11:e0005711. [PMID: 28671959 PMCID: PMC5510890 DOI: 10.1371/journal.pntd.0005711] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 07/14/2017] [Accepted: 06/13/2017] [Indexed: 12/18/2022] Open
Abstract
Background Convulsions with fever in children are a common neurologic emergency in the tropics, and determining the contribution of endemic viral infections can be challenging. In particular, there is a dearth of data on the prevalence and clinical differentiation of Lassa virus disease (LVD) in febrile children in endemic areas of Nigeria, which has multiple lineages of the virus. The aim of this study was to determine the prevalence and presentation of LVD in febrile children with and without convulsions. Methodology/Principal findings This was a prospective study of consecutive febrile children aged ≥1 month– 15 years admitted to the Children’s Emergency Room of Irrua Specialist Teaching Hospital over a period of 1 year. Febrile children with convulsions (Cases) were compared with those without convulsions (Controls). LVD was defined by the presence of a positive Lassa virus RT-PCR test. Rates were compared between groups using χ2 or Fisher’s exact tests and p <0.05 taken as significant. 373 (40.9%) of 913 admissions had fever. Of these, 108/373 (29%) presented with convulsions. The overall prevalence of LVD was 13/373 (3.5%; 95% CI = 1.9%, 5.7%) in febrile admissions, 3/108 (2.8%) in Cases and 10/265 (3.8%) in Controls [(Odds Ratio (95% Confidence Interval) (OR (95% CI)) of LVD in Cases versus Controls = 0.73 (0.2, 2.7)]. Only vomiting (OR (95% CI) = 0.09 (0.01, 0.70)) and bleeding (OR (95% CI) = 39.56 (8.52, 183.7)) were significantly associated with an increased prevalence of LVD. Conclusions/Significance LVD is an important cause of fever, including undifferentiated fever in children in endemic areas, but it is not significantly associated with convulsions associated with fever. Its prevalence, and lack of clinical differentiation on presentation, underscores the importance of a high index of suspicion in diagnosis. Screening of febrile children with undifferentiated fever in endemic areas for LVD could be an important medical and public health control measure. There has, perhaps, been undue focus on malaria as a cause of childhood fever and convulsions, often with delayed/missed diagnosis of other serious prevalent infections, and correspondingly very little published data on the contribution of Lassa virus disease (LVD) in endemic areas. There is also very little published data on the contribution of LVD to childhood morbidity and mortality in Nigeria, a large LVD-endemic country that has in circulation 3 of the 4 currently known lineages of the Lassa virus. This study was carried out to address these gaps. The results should also be of relevance in the formulation of policies for the treatment and control of viral haemorrhagic fevers. The prevalence of LVD was 5.4% among children with clinically undifferentiated fever (n = 243); 3.9% among those with convulsions associated with fever (n = 77) and 6.0% among those with fever but no convulsions (n = 166). The results underscore the importance of LVD as a cause of acute undifferentiated fever. The results also underscore the need of diagnostic testing for LVD in children with acute undifferentiated fever in endemic areas in order to facilitate control, including the prevention of nosocomial transmission.
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Affiliation(s)
- Odigie C. Akhuemokhan
- Department of Paediatrics, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | | | - Nosa Akpede
- Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - Jacqueline Ehimuan
- Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - Donatus I. Adomeh
- Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - Ikpomwonsa Odia
- Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - Sylvia C. Olomu
- Department of Paediatrics, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - Meike Pahlmann
- Bernhard-Nocht-Institute for Tropical Medicine, WHO Collaborating Centre for Arboviruses and Hemorrhagic Fever Reference and Research, Department of Virology, Bernhard-Nocht-Str. 74, Hamburg, Germany
| | - Beate Becker-Ziaja
- Bernhard-Nocht-Institute for Tropical Medicine, WHO Collaborating Centre for Arboviruses and Hemorrhagic Fever Reference and Research, Department of Virology, Bernhard-Nocht-Str. 74, Hamburg, Germany
| | - Christian T. Happi
- Malaria Research Laboratory, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Danny A. Asogun
- Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - Sylvanus A. Okogbenin
- Department of Obstetrics and Gynaecology, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - Peter O. Okokhere
- Department of Medicine, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - Osagie S. Dawodu
- Department of Paediatrics, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - Irekpono U. Omoike
- Department of Paediatrics, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - Pardis C. Sabeti
- Department of Organismic Biology, Broad Institute, Harvard University, Cambridge, Massachusetts, United States of America
| | - Stephan Günther
- Bernhard-Nocht-Institute for Tropical Medicine, WHO Collaborating Centre for Arboviruses and Hemorrhagic Fever Reference and Research, Department of Virology, Bernhard-Nocht-Str. 74, Hamburg, Germany
| | - George O. Akpede
- Department of Paediatrics, Faculty of Clinical Sciences, College of Medicine, Ambrose Alli University, Ekpoma, Edo State, Nigeria
- * E-mail:
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He R, Han W, Song X, Tang X, Cheng L, Jiang L. Effect of fasudil on cognitive function following status convulsion in rats. Mol Med Rep 2017; 16:119-126. [PMID: 28534935 PMCID: PMC5482154 DOI: 10.3892/mmr.2017.6615] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 03/03/2017] [Indexed: 12/22/2022] Open
Abstract
Fasudil has been demonstrated to possess a protective effect in neural injury; however, its protective effect on convulsive brain injury remains to be assessed. The aim of the present study was to investigate the latent mechanism and effect of fasudil on cognitive function following status convulsion (SC) in rats. Initially, to determine the effects of SC, the expression levels of Ras homolog gene family, member A (RhoA)/Rho-associated protein kinase (ROCK) signaling pathway-associated proteins were measured by western blot analysis in 16 rats. To investigate the effects of fasudil on cognitive function in SC rats, a further 40 rats were assigned to four groups: Group I (healthy untreated rats), group II (healthy rats treated with fasudil), group III (SC rats) and group IV (SC rats treated with fasudil). An object-in-place memory task and the Morris Water Maze test were subsequently performed. Histopathological alterations in brain tissue and SC latency were additionally analyzed. Following SC, protein expression levels of myelin-associated glycoprotein, myelin oligodendrocyte glycoprotein and leucine rich repeat and immunoglobulin-like domain-containing protein 1 were significantly increased (P<0.05) and levels of neurite outgrowth inhibitor protein A were significantly decreased (P<0.01). SC had no effect on RhoA level (P=0.921); however, it significantly increased the levels of phosphorylated RhoA (P<0.01). Cognitive function was significantly decreased following SC and significantly increased following fasudil intervention. Fasudil intervention improved CA1 structure, which was lost following SC. SC severely impaired cognitive function and affected the expression of neurite growth inhibitory factors. Fasudil treatment improved cognitive function and central nervous system (CNS) injury, and decreased SC susceptibility in rats. Fasudil and SC may regulate the CNS by affecting the expression of neurite growth inhibitory factors in the RhoA/ROCK signaling pathway.
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Affiliation(s)
- Rong He
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing 400014, P.R. China
| | - Wei Han
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing 400014, P.R. China
| | - Xiaojie Song
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing 400014, P.R. China
| | - Xiaoju Tang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing 400014, P.R. China
| | - Li Cheng
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing 400014, P.R. China
| | - Li Jiang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing 400014, P.R. China
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Ibinda F, Odermatt P, Kariuki SM, Kakooza-Mwesige A, Wagner RG, Owusu-Agyei S, Masanja H, Ngugi AK, Mbuba CK, Doku VCK, Neville BG, Sander JW, Newton CRJC. Magnitude and factors associated with nonadherence to antiepileptic drug treatment in Africa: A cross-sectional multisite study. Epilepsia Open 2017; 2:226-235. [PMID: 29588951 PMCID: PMC5719857 DOI: 10.1002/epi4.12052] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2017] [Indexed: 12/30/2022] Open
Abstract
Objectives The epilepsy treatment gap is large in low‐ and middle‐income countries, but the reasons behind nonadherence to treatment with antiepileptic drugs (AEDs) across African countries remain unclear. We investigated the extent to which AEDs are not taken and associated factors in people with active convulsive epilepsy (ACE) identified in cross‐sectional studies conducted in five African countries. Methods We approached 2,192 people with a confirmed diagnosis of ACE for consent to give blood voluntarily. Participants were asked if they were taking AEDs, and plasma drug concentrations were measured using a fluorescence polarization immunoassay analyzer. Information about possible risk factors was collected using questionnaire‐based clinical interviews. We determined factors associated with nonadherence to AED treatment in children and adults, as measured by detectable and optimal levels, using multilevel logistic regression. Results In 1,303 samples assayed (43.7% were children), AEDs were detected in 482, but only 287 had optimal levels. Of the 1,303 samples, 532 (40.8%) were from people who had reported they were on AEDs. The overall prevalence of nonadherence to treatment was 63.1% (95% confidence interval [CI] 60.5–65.6%) as measured by detectable AED levels and 79.1% (95% CI 73.3–84.3%) as measured by optimal AED levels; self‐reported nonadherence was 65.1% (95% CI 45.0–79.5%). Nonadherence was significantly (p < 0.001) more common among the children than among adults for optimal and detectable levels of AEDs, as was the self‐reported nonadherence. In children, lack of previous hospitalization and learning difficulties were independently associated with nonadherence to treatment. In adults, history of delivery at home, absence of burn marks, and not seeking traditional medicine were independently associated with the nonadherence to AED treatment. Significance Only about 20% of people with epilepsy benefit fully from antiepileptic drugs in sub‐Saharan Africa, according to optimum AEDs levels. Children taking AEDs should be supervised to promote compliance.
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Affiliation(s)
- Fredrick Ibinda
- Centre for Geographic Medicine Research (Coast) Kenya Medical Research Institute Kilifi Kenya.,Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana
| | - Peter Odermatt
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana.,Department of Public Health and Epidemiology Swiss Tropical and Public Health Institute Basel Switzerland.,University of Basel Basel Switzerland
| | - Symon M Kariuki
- Centre for Geographic Medicine Research (Coast) Kenya Medical Research Institute Kilifi Kenya.,Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana
| | - Angelina Kakooza-Mwesige
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana.,Iganga-Mayuge Health and Demographic Surveillance System Kampala Uganda.,Department of Paediatrics and Child Health Makerere University College of Health Sciences Kampala Uganda
| | - Ryan G Wagner
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana.,MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt) School of Public Health Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa.,Department of Public Health and Clinical Medicine Epidemiology and Public Health Sciences Umeå University Umeå Sweden
| | - Seth Owusu-Agyei
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana.,Kintampo Health Research Centre Kintampo Ghana
| | - Honorati Masanja
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana.,Ifakara Health InstituteI fakara Tanzania
| | - Anthony K Ngugi
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana.,Research Support Unit Faculty of Health Sciences Aga Khan University-East Africa Nairobi Kenya
| | - Caroline K Mbuba
- Department of Public Health School of Medicine and Health Sciences Kenya Methodist University Meru Kenya
| | - Victor C K Doku
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana.,Institute of Psychiatry Kings College London London United Kingdom
| | - Brian G Neville
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana.,Neurosciences Unit Institute of Child Health University College London London United Kingdom
| | - Josemir W Sander
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana.,NIHR University College London Hospitals Biomedical Research Centre UCL Institute of Neurology Queen Square United Kingdom.,Epilepsy Society Chalfont St. Peter United Kingdom.,Stichting Epilepsie Instellingen Nederland (SEIN) SW Heemstede the Netherlands
| | - Charles R J C Newton
- Centre for Geographic Medicine Research (Coast) Kenya Medical Research Institute Kilifi Kenya.,Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS)-INDEPTH Network Accra Ghana.,Neurosciences Unit Institute of Child Health University College London London United Kingdom.,Department of Psychiatry University of Oxford Oxford United Kingdom
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Kariuki SM, Abubakar A, Stein A, Marsh K, Newton CRJC. Prevalence, causes, and behavioral and emotional comorbidities of acute symptomatic seizures in Africa: A critical review. Epilepsia Open 2017; 2:8-19. [PMID: 29750209 PMCID: PMC5939456 DOI: 10.1002/epi4.12035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2016] [Indexed: 12/19/2022] Open
Abstract
Seizures with fever includes both febrile seizures (due to nonneurological febrile infections) and acute symptomatic seizures (due to neurological febrile infections). The cumulative incidence (lifetime prevalence) of febrile seizures in children aged ≤6 years is 2-5% in American and European studies, but there are no community-based data on acute symptomatic seizures in Africa. The incidence of acute symptomatic seizures in sub-Saharan Africa is more than twice that in high-income countries. However, most studies of acute symptomatic seizures from Africa are based on hospital samples or do not conduct surveys in demographic surveillance systems, which underestimates the burden. It is difficult to differentiate between febrile seizures and acute symptomatic seizures in Africa, especially in malaria-endemic areas where malaria parasites can sequester in the brain microvasculature; but this challenge can be addressed by robust identification of underlying causes. The proportion of complex acute symptomatic seizures (i.e., seizures that are focal, repetitive, or prolonged) in Africa are twice that reported in other parts of the world (>60% vs. ∼30%), which is often attributed to falciparum malaria. These complex phenotypes of acute symptomatic seizures can be associated with behavioral and emotional problems in high-income countries, and outcomes may be even worse in Africa. One Kenyan study reported behavioral and emotional problems in approximately 10% of children admitted with acute symptomatic seizures, but it is not clear whether the behavioral and emotional problems were due to the seizures, shared genetic susceptibility, etiology, or underlying neurological damage. The underlying neurological damage in acute symptomatic seizures can lead not only to behavioral and emotional problems but also to neurocognitive impairment and epilepsy. Electroencephalography may have a prognostic role in African children with acute symptomatic seizures. There are significant knowledge gaps regarding acute symptomatic seizures in Africa, which results in lack of reliable estimates for planning interventions. Future epidemiological studies of acute symptomatic seizures should be set up in Africa.
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Affiliation(s)
| | - Amina Abubakar
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Department of Public HealthPwani UniversityKilifiKenya
- Department of PsychiatryUniversity of OxfordOxfordUnited Kingdom
| | - Alan Stein
- Department of PsychiatryUniversity of OxfordOxfordUnited Kingdom
| | - Kevin Marsh
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Nuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
- Alliance for Accelerating Excellence in Science in AfricaAfrican Academy of SciencesNairobiKenya
| | - Charles R. J. C. Newton
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Department of PsychiatryUniversity of OxfordOxfordUnited Kingdom
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Sodium Disturbances in Children Admitted to a Kenyan Hospital: Magnitude, Outcome and Associated Factors. PLoS One 2016; 11:e0161320. [PMID: 27603309 PMCID: PMC5014322 DOI: 10.1371/journal.pone.0161320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 08/03/2016] [Indexed: 01/16/2023] Open
Abstract
Background Perturbations of blood sodium are the most frequently encountered electrolyte disorder in sick children, and may influence fluid therapy. We examined the frequency of blood sodium perturbations, and factors and outcomes associated with hyponatremia in children admitted to a rural Kenyan hospital and investigated the risk factors associated with deaths in hyponatremic children. Methods Plasma sodium levels and other laboratory parameters were measured in children admitted to a rural Kenyan hospital. Clinical measurements were collected using standard forms and entered into a computer database. The proportion of children admitted with hyponatremia was determined. Logistic regression models were used to investigate factors associated with hyponatremia, and death in those with hyponatremia. Results Abnormal plasma sodium occurred in 46.6% (95% confidence interval (95%CI) 43.5–49.6%) of 1026 pediatric admissions. Hyponatremia occurred in 44.4% (95%CI 41.4–47.5%) and hypernatremia in 2.1% (95%CI 1.3–3.0%). Malaria (40.8%) was the most common underlying primary diagnosis in hyponatremic children. Malaria, hyperglycemia, wasting, high creatinine levels and preserved consciousness were associated with hyponatremia. Pallor and seizures were associated with increased mortality in hyponatremic children. Conclusions Sodium disturbances are common in pediatric admissions to a County hospital in rural Kenya. Seizures and pallor were predictors of mortality in hyponatremic children.
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Status Epilepticus: Epidemiology and Public Health Needs. J Clin Med 2016; 5:jcm5080071. [PMID: 27537921 PMCID: PMC4999791 DOI: 10.3390/jcm5080071] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 08/08/2016] [Accepted: 08/10/2016] [Indexed: 11/17/2022] Open
Abstract
Status epilepticus (SE) is defined as a continuous clinical and/or electrographic seizure activity lasting five minutes or more or recurrent seizure activity without return to baseline. There is a paucity of epidemiological studies of SE, as most research is derived from small population studies. The overall incidence of SE is 9.9 to 41 per 100,000/year, with peaks in children and the elderly and with febrile seizures and strokes as its main etiologies. The etiology is the major determinant of mortality. Governments and the academic community should predominantly focus on the primary prevention of etiologies linked to SE, as these are the most important risk factors for its development. This review describes the incidence, prevalence, etiology, risk factors, outcomes and costs of SE and aims to identify future research and public health needs.
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Interleukin-1 receptor is a target for adjunctive control of diazepam-refractory status epilepticus in mice. Neuroscience 2016; 328:22-9. [PMID: 27133574 DOI: 10.1016/j.neuroscience.2016.04.036] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 04/20/2016] [Accepted: 04/23/2016] [Indexed: 12/13/2022]
Abstract
Proinflammatory cytokine interleukin-1 beta (IL-1β) may accumulate in the brain during status epilepticus, but whether it contributes to the progressive refractoriness of SE remains unclear. By using a kainic acid-induced SE mice model, we tested whether pharmacological blockade or knock-out of interleukin-1 receptor type 1 (IL-1R1) could influence the diazepam-refractory phenomenon of prolonged SE. We confirmed diazepam failed to terminate prolonged SE (allowed to continue for 40min before diazepam administration). The expression level of IL-1β in the hippocampus during prolonged SE was significantly higher than that of baseline. Interestingly, prolonged SE was not diazepam-refractory in IL-1R1 knock-out mice. Moreover, administration of interleukin-1 receptor antagonist (IL-1RA) combined with diazepam terminated established prolonged SE, while IL-1RA alone is not capable to terminate prolonged SE. On the contrary, administration of recombinant human IL-1β weakens the efficacy of diazepam by prolonging its latency to terminate non-prolonged SE. Thus, the present study provides direct evidence that accumulated IL-1β contributed to the diazepam refractoriness of prolonged SE, and suggests that interleukin-1 receptor is a target for adjunctive control of diazepam-refractory SE.
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Lingappa L, Konanki R, Patel R, Vooturi S, Jayalakshmi S. Clinical profile and outcome of refractory convulsive status epilepticus in older children from a developing country. Seizure 2016; 36:31-35. [DOI: 10.1016/j.seizure.2016.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/24/2016] [Accepted: 01/26/2016] [Indexed: 10/22/2022] Open
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Kaputu-Kalala-Malu C. [Epilepsy and acute seizures in childhood in sub-Saharan Africa: challenges and hopes]. Pan Afr Med J 2016; 23:58. [PMID: 27217883 PMCID: PMC4862802 DOI: 10.11604/pamj.2016.23.58.3273] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 08/20/2015] [Indexed: 01/05/2023] Open
Abstract
Epilepsy is a neurological disease common among children in sub-Saharan Africa (SSA). Although its exact prevalence in this population is unknown, it is probably similar to that found in the general population because of its early onset (60% starts before the age of 20 years) and the absence of bimodal distribution found in western countries. This review acknowledges the reality that current management of pediatric epilepsy in SSA is imperfect. To reverse this trend, the challenges are three fold: better education, improved therapeutics and more research. Doctors need to be trained in the practice of pediatric neurology and provided with working conditions that limit the brain drain. The resources necessary for the proper management of children with epilepsy in SSA need to be identified and provided (better availability of antiepileptic drugs, clear national guidelines, proper registration of traditional healers etc…). Finally, it is imperative that research be conducted to establish accurate incidence and prevalence figures for pediatric epilepsy, so that targeted control measures can be implemented.
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Affiliation(s)
- Célestin Kaputu-Kalala-Malu
- Service of Child Neurology, Department of Neurology, Kinshasa School of Medicine, University of Kinshasa, Republic Democratic of Congo
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Serem GK, Newton CR, Kariuki SM. Incidence, causes and phenotypes of acute seizures in Kenyan children post the malaria-decline period. BMC Neurol 2015; 15:180. [PMID: 26444670 PMCID: PMC4596303 DOI: 10.1186/s12883-015-0444-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 09/29/2015] [Indexed: 12/11/2022] Open
Abstract
Background Acute seizures are a common cause of paediatric admissions to hospitals in Africa, and malaria is an important cause of seizures in endemic areas. Malaria has declined in the past decade whilst neonatal admissions have increased, both which may affect the incidence and phenotypes of acute seizures in African children. Methods We examined the effect of recent decline in malaria and the increasing burden of neonatal admissions on the incidence, causes and phenotypes of acute seizures admitted to hospital from 2009–2013. We used logistic regression to measure associations and Poisson regression to calculate the incidence and rate ratios. Results The overall incidence of acute seizures over the 5-year period was 312 per 100,000/year (95 % CI, 295–329): 116 per 100,000/year (95 % CI, 106–127) for complex seizures and 443 per 100,000 live births (95 % CI, 383–512) for neonatal seizures. Over the period, there was an increase in incidence of seizures-attributable to malaria (SAM) (incidence rate ratio (IRR) = 1.25; p < 0.001), but neither non-SAM (IRR = 1.03; p = 0.569) nor neonatal seizures (IRR = 0.99; p = 0.905). Important causes of acute seizures were malaria (33 %) and respiratory tract infections (19 %); and for neonatal seizures were neonatal sepsis (51 %), hypoglycemia (41 %) and hypoxic-ischemic encephalopathy (21 %). Mortality occurred in 6 % of all acute seizures, being more common in complex seizures (8 %) and neonatal seizures (10 %) than other seizures (p < 0.001 for both comparisons). Conclusions Acute seizures remain common in children despite a decline in the incidence of malaria; suggesting that causes for these seizures need to be prevented in the community.
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Affiliation(s)
- George K Serem
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya.
| | - Charles Rjc Newton
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya. .,Department of Psychiatry, University of Oxford, Oxford, UK.
| | - Symon M Kariuki
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya. .,Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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Kariuki SM, White S, Chengo E, Wagner RG, Ae-Ngibise KA, Kakooza-Mwesige A, Masanja H, Ngugi AK, Sander JW, Neville BG, Newton CR. Electroencephalographic features of convulsive epilepsy in Africa: A multicentre study of prevalence, pattern and associated factors. Clin Neurophysiol 2015; 127:1099-1107. [PMID: 26337840 PMCID: PMC4725253 DOI: 10.1016/j.clinph.2015.07.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 07/22/2015] [Accepted: 07/28/2015] [Indexed: 12/27/2022]
Abstract
Electroencephalographic abnormalities are common in Africans with epilepsy, with an adjusted prevalence of 2.7 (95% confidence interval, 2.5–2.9) per 1000 population. Electroencephalographic abnormalities are associated with preventable factors such as adverse perinatal events and frequent seizures. Electroencephalography is helpful in identifying focal epilepsy in Africa, where timing of focal aetiologies is problematic and there is a lack of neuroimaging services.
Objective We investigated the prevalence and pattern of electroencephalographic (EEG) features of epilepsy and the associated factors in Africans with active convulsive epilepsy (ACE). Methods We characterized electroencephalographic features and determined associated factors in a sample of people with ACE in five African sites. Mixed-effects modified Poisson regression model was used to determine factors associated with abnormal EEGs. Results Recordings were performed on 1426 people of whom 751 (53%) had abnormal EEGs, being an adjusted prevalence of 2.7 (95% confidence interval (95% CI), 2.5–2.9) per 1000. 52% of the abnormal EEG had focal features (75% with temporal lobe involvement). The frequency and pattern of changes differed with site. Abnormal EEGs were associated with adverse perinatal events (risk ratio (RR) = 1.19 (95% CI, 1.07–1.33)), cognitive impairments (RR = 1.50 (95% CI, 1.30–1.73)), use of anti-epileptic drugs (RR = 1.25 (95% CI, 1.05–1.49)), focal seizures (RR = 1.09 (95% CI, 1.00–1.19)) and seizure frequency (RR = 1.18 (95% CI, 1.10–1.26) for daily seizures; RR = 1.22 (95% CI, 1.10–1.35) for weekly seizures and RR = 1.15 (95% CI, 1.03–1.28) for monthly seizures)). Conclusions EEG abnormalities are common in Africans with epilepsy and are associated with preventable risk factors. Significance EEG is helpful in identifying focal epilepsy in Africa, where timing of focal aetiologies is problematic and there is a lack of neuroimaging services.
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Affiliation(s)
- Symon M Kariuki
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya; Nuffield Department of Medicine, University of Oxford, OX3 7BN Oxford, UK.
| | - Steven White
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, WC1N 3JH London, UK
| | - Eddie Chengo
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya; Foundation for People with Epilepsy, 80200 Malindi, Kenya
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, P.O. Box 2 Cornhoek 1360, Johannesburg, South Africa; Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, 901 85 Umeå, Sweden
| | - Kenneth A Ae-Ngibise
- Kintampo Health and Demographic Surveillance System, P.O. Box 200, Kintampo, Ghana
| | - Angelina Kakooza-Mwesige
- Iganga-Mayuge Health and Demographic Surveillance System, P.O. Box 111, Iganga, Uganda; Department of Paediatrics and Child Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Honorati Masanja
- Ifakara Health and Demographic Surveillance System, P.O. Box 78373, Ifakara, Tanzania
| | - Anthony K Ngugi
- Population Health Sciences/Research Support Unit, Faculty of Health Sciences, Aga Khan University (East Africa), Aga Khan Hospital Building, Third Parklands Ave., P.O. Box 30270, Nairobi, Kenya
| | - Josemir W Sander
- NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG and Epilepsy Society, Chalfont St. Peter SL9 8ES, Bucks, UK; Stichting Epilepsie Instellingen Nederland-SEIN, 2103SW Heemstede, Netherlands
| | - Brian G Neville
- Neurosciences Unit, UCL Institute of Child Health, WC1E 6BT London, UK
| | - Charles R Newton
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230, Kilifi, Kenya; Department of Psychiatry, University of Oxford, OX3 7JX Oxford, UK
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Maegaki Y, Kurozawa Y, Tamasaki A, Togawa M, Tamura A, Hirao M, Nagao A, Kouda T, Okada T, Hayashibara H, Harada Y, Urushibara M, Sugiura C, Sejima H, Tanaka Y, Matsuda-Ohtahara H, Kasai T, Kishi K, Kaji S, Toyoshima M, Kanzaki S, Ohno K. Early predictors of status epilepticus-associated mortality and morbidity in children. Brain Dev 2015; 37:478-86. [PMID: 25193404 DOI: 10.1016/j.braindev.2014.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 06/21/2014] [Accepted: 08/07/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Early predictors of status epilepticus (SE)-associated mortality and morbidity have not been systematically studied in children, considerably impeding the identification of patients at risk. OBJECTIVES To determine reliable early predictors of SE-associated mortality and morbidity and identify the etiology of SE-associated sequelae in Japanese children. METHODS We conducted a prospective multicenter study of clinical findings and initial laboratory data acquired at SE onset, and assessed outcomes at the last follow-up examination. In-hospital death during the acute period and neurological sequelae were classified as poor outcomes. RESULTS Of the 201 children who experienced their first SE episode, 16 exhibited poor outcome that was most commonly associated with acute encephalopathy. Univariate analysis revealed that the following were associated with poor outcomes: young age (⩽24 months); seizure duration >90 min; seizure intractability (failure of the second anticonvulsive drug); biphasic seizures; abnormal blood glucose levels (<61 or >250 mg/dL); serum aspartate aminotransferase (AST) ⩾56 U/L; and C-reactive protein (CRP) levels >2.00 mg/dL. Multivariate analysis revealed that young age, seizure intractability, abnormal blood glucose levels, and elevated AST and CRP levels were statistically significant. CONCLUSIONS Young age and seizure intractability were highly predictive of poor outcomes in pediatric SE. Moreover, abnormal blood glucose levels and elevated AST and CRP levels were predictors that might be closely associated with the etiology, especially acute encephalopathy and severe bacterial infection (sepsis and meningitis) in Japanese children.
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Affiliation(s)
- Yoshihiro Maegaki
- Division of Child Neurology, Faculty of Medicine, Tottori University, Yonago, Japan.
| | - Youichi Kurozawa
- Division of Health Administration and Promotion, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Akiko Tamasaki
- Division of Child Neurology, Faculty of Medicine, Tottori University, Yonago, Japan
| | | | - Akiko Tamura
- Tottori Prefecture Central Hospital, Tottori, Japan
| | | | | | | | | | | | | | - Makoto Urushibara
- Tottori Prefecture Saiseikai Sakaiminato General Hospital, Sakaiminato, Japan
| | - Chitose Sugiura
- Tottori Prefectural Rehabilitation Center for Disabled Children, Yonago, Japan
| | | | | | | | | | - Kazuko Kishi
- Shimane University School of Medicine, Izumo, Japan
| | | | | | - Susumu Kanzaki
- Division of Pediatrics and Perinatology, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Kousaku Ohno
- Division of Child Neurology, Faculty of Medicine, Tottori University, Yonago, Japan
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