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Makhado L, Maphula A, Ngomba RT, Musekwa OP, Makhado TG, Nemathaga M, Rammela M, Munyadziwa M, Striano P. Epilepsy in rural South Africa: Patient experiences and healthcare challenges. Epilepsia Open 2024; 9:1565-1574. [PMID: 38884148 PMCID: PMC11296125 DOI: 10.1002/epi4.12999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/29/2024] [Accepted: 06/05/2024] [Indexed: 06/18/2024] Open
Abstract
OBJECTIVE This study investigates the prevalent issues of healthcare access and the impact of antiseizure treatments among people with epilepsy (PWE) in rural Limpopo and Mpumalanga, South Africa, where healthcare facilities and affordable treatments are often inadequate. METHODS Using a cross-sectional survey, 162 PWE were selected using multistage sampling across the provinces. Data were collected via a structured questionnaire and analyzed descriptively using SPSS v27. RESULTS Most of the participants experienced seizures intermittently, with 70.6% in Limpopo and 53.3% in Mpumalanga reporting occasional episodes, whereas a significant minority in both regions-20.6% and 40%, respectively-suffered from frequent seizures. A notable portion of PWE also reported recurring side effects from antiseizure drugs, which led to consequential life disruptions, including educational dropout and unemployment. SIGNIFICANCE The findings underscore an urgent need for enhanced educational programs and increased awareness to improve the understanding and management of epilepsy in these underserved areas. Optimizing care for PWE requires a multifaceted approach, including evaluating healthcare accessibility, affordability, and societal beliefs influencing treatment adherence. The study advocates for government and policy interventions to mitigate the quality of life deterioration caused by epilepsy and its treatment in rural communities. PLAIN LANGUAGE SUMMARY In Limpopo and Mpumalanga, many individuals with epilepsy experience seizures occasionally, while a significant minority have them frequently. Numerous people also suffer recurring side effects from antiseizure medications, impacting their lives severely by causing school dropouts and job losses. This underscores the urgent need for improved education and awareness programs to manage epilepsy in these provinces effectively. The study urges government action and policy reforms to enhance care and support for people with epilepsy in rural areas, aiming to improve their quality of life.
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Affiliation(s)
- Lufuno Makhado
- Department of Public Health, Faculty of Health SciencesUniversity of VendaThohoyandouLimpopo ProvinceSouth Africa
| | - Angelina Maphula
- Department of Psychology, Faculty of Health SciencesUniversity of VendaThohoyandouLimpopo ProvinceSouth Africa
| | - Richard Teke Ngomba
- School of PharmacyUniversity of Lincoln, Joseph Banks LaboratoriesLincolnshireUK
| | - Ofhani Prudance Musekwa
- Department of Psychology, Faculty of HumanitiesUniversity of JohannesburgJohannesburgSouth Africa
| | - Thendo Gertie Makhado
- Department of Advanced Nursing Sciences, Faculty of Health SciencesUniversity of VendaThohoyandouLimpopo ProvinceSouth Africa
| | - Muofheni Nemathaga
- Department of Advanced Nursing Sciences, Faculty of Health SciencesUniversity of VendaThohoyandouLimpopo ProvinceSouth Africa
| | - Mukovhe Rammela
- Department of Public Health, Faculty of Health SciencesUniversity of VendaThohoyandouLimpopo ProvinceSouth Africa
| | - Muimeleli Munyadziwa
- Department of Public Health, Faculty of Health SciencesUniversity of VendaThohoyandouLimpopo ProvinceSouth Africa
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases UnitIRCCS Istituto Giannina GasliniGenoaItaly
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of GenovaGenoaItaly
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Daniłowska K, Picheta N, Żyła D, Piekarz J, Zych K, Gil-Kulik P. New Pharmacological Therapies in the Treatment of Epilepsy in the Pediatric Population. J Clin Med 2024; 13:3567. [PMID: 38930098 PMCID: PMC11204858 DOI: 10.3390/jcm13123567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Epilepsy is a disorder characterized by abnormal brain neuron activity, predisposing individuals to seizures. The International League Against Epilepsy (ILAE) categorizes epilepsy into the following groups: focal, generalized, generalized and focal, and unknown. Infants are the most vulnerable pediatric group to the condition, with the cause of epilepsy development being attributed to congenital brain developmental defects, white matter damage, intraventricular hemorrhage, perinatal hypoxic-ischemic injury, perinatal stroke, or genetic factors such as mutations in the Sodium Channel Protein Type 1 Subunit Alpha (SCN1A) gene. Due to the risks associated with this condition, we have investigated how the latest pharmacological treatments for epilepsy in children impact the reduction or complete elimination of seizures. We reviewed literature from 2018 to 2024, focusing on the age group from 1 month to 18 years old, with some studies including this age group as well as older individuals. The significance of this review is to present and compile research findings on the latest antiseizure drugs (ASDs), their effectiveness, dosing, and adverse effects in the pediatric population, which can contribute to selecting the best drug for a particular patient. The medications described in this review have shown significant efficacy and safety in the studied patient group, outweighing the observed adverse effects. The main aim of this review is to provide a comprehensive summary of the current state of knowledge regarding the newest pharmacotherapy for childhood epilepsy.
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Affiliation(s)
- Karolina Daniłowska
- Student’s Scientific Society of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland; (K.D.); (N.P.); (D.Ż.); (J.P.); (K.Z.)
| | - Natalia Picheta
- Student’s Scientific Society of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland; (K.D.); (N.P.); (D.Ż.); (J.P.); (K.Z.)
| | - Dominika Żyła
- Student’s Scientific Society of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland; (K.D.); (N.P.); (D.Ż.); (J.P.); (K.Z.)
| | - Julia Piekarz
- Student’s Scientific Society of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland; (K.D.); (N.P.); (D.Ż.); (J.P.); (K.Z.)
| | - Katarzyna Zych
- Student’s Scientific Society of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland; (K.D.); (N.P.); (D.Ż.); (J.P.); (K.Z.)
| | - Paulina Gil-Kulik
- Department of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland
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Ferretti A, Riva A, Fabrizio A, Bruni O, Capovilla G, Foiadelli T, Orsini A, Raucci U, Romeo A, Striano P, Parisi P. Best practices for the management of febrile seizures in children. Ital J Pediatr 2024; 50:95. [PMID: 38735928 PMCID: PMC11089695 DOI: 10.1186/s13052-024-01666-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/28/2024] [Indexed: 05/14/2024] Open
Abstract
Febrile seizures (FS) are commonly perceived by healthcare professionals as a self-limited condition with a generally 'benign' nature. Nonetheless, they frequently lead to pediatric consultations, and their management can vary depending on the clinical context. For parents and caregivers, witnessing a seizure can be a distressing experience, significantly impacting their quality of life. In this review, we offer an in-depth exploration of FS management, therapeutic interventions, and prognostic factors, with the aim of providing support for physicians and enhancing communication with families. We conducted a comprehensive literature search using the PubMed and Web of Science databases, spanning the past 50 years. The search terms utilized included "febrile seizure," "complex febrile seizure," "simple febrile seizure," in conjunction with "children" or "infant." Only studies published in English or those presenting evidence-based data were included in our assessment. Additionally, we conducted a cross-reference search to identify any additional relevant data sources. Our thorough literature search resulted in a compilation of references, with carefully selected papers thoughtfully integrated into this review.
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Affiliation(s)
- Alessandro Ferretti
- Pediatrics Unit, Neurosciences, Mental Health and Sensory Organ (NESMOS) Department, Faculty of Medicine and Psychology, S. Andrea Hospital, Sapienza University, via di Grottarossa 1035/1039, Rome, 00189, Italy.
| | - Antonella Riva
- IRCCS Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Alice Fabrizio
- Pediatrics Unit, Neurosciences, Mental Health and Sensory Organ (NESMOS) Department, Faculty of Medicine and Psychology, S. Andrea Hospital, Sapienza University, via di Grottarossa 1035/1039, Rome, 00189, Italy
| | - Oliviero Bruni
- Department of Social and Developmental Psychology, S. Andrea Hospital, Sapienza University, Rome, Italy
| | - Giuseppe Capovilla
- Child Neuropsychiatry Department, Epilepsy Center, Mantova, Italy
- C. Poma HospitalFondazione Poliambulanza, Brescia, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandro Orsini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Umberto Raucci
- General and Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonino Romeo
- Fatebenefratelli Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Pasquale Striano
- IRCCS Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Pasquale Parisi
- Pediatrics Unit, Neurosciences, Mental Health and Sensory Organ (NESMOS) Department, Faculty of Medicine and Psychology, S. Andrea Hospital, Sapienza University, via di Grottarossa 1035/1039, Rome, 00189, Italy
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Shao L, Yu Y. Development of a prediction nomogram model of recurrent febrile seizures in pediatric children. Eur J Pediatr 2023; 182:4875-4888. [PMID: 37597045 DOI: 10.1007/s00431-023-05133-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/10/2023] [Accepted: 07/22/2023] [Indexed: 08/21/2023]
Abstract
The purpose of this study is to develop a prediction nomogram of recurrent febrile seizures in pediatric children based on the identified predictors for developing recurrent febrile seizures. This is a retrospective observational study. The medical records of 320 febrile seizure-afflicted children admitted to Zhoushan Women and Children Hospital from March 2019 to January 2023 were retrospectively reviewed. Children were divided into the recurrent febrile seizures group and the non-recurrent febrile seizures group. The predictors of recurrent febrile seizures were identified by univariate and multivariate analyses. A prediction nomogram model was developed via R software. The performance of the nomogram was internally validated to assess the model's discrimination and consistency, and decision curve analysis was employed to assess clinical utility. There were 41 out of 320 cases that had recurrent febrile seizures during the observation period, with a 12.81% prevalence rate of recurrent febrile seizures. The predictors of recurrent febrile seizures were young age at the first febrile seizures, a family history of febrile seizures in a first-degree relative, diurnal variation of initial febrile seizures occurrence, gender, and a low level of C-reactive protein. The area under the receiver operating characteristic curve of the nomogram is 0.795 (95% confidence interval: 0.720-0.871). Calibration plots and the result of the Hosmer-Lemeshow test (P = 0.472) reveal satisfactory consistency. Decision curve analysis showed a significant net benefit of the nomogram. CONCLUSIONS The prediction nomogram model demonstrates good performance and clinical utility, which would be a convenient tool for the detection of children in pediatrics with high-risk recurrent febrile seizures. It is useful for pediatric medical staff to provide early medical interventions and family counseling. WHAT IS KNOWN • A proportion of children experience recurrences of febrile seizures. • Recognition of risk factors for recurrent FS in pediatrics would be useful for the prediction of risk probabilities and help provide tailored counseling and follow-up. WHAT IS NEW • A nomogram model is developed for risk prediction of recurrent febrile seizures in this study, which would be a convenient risk prediction tool in pediatrics. • The predictor of diurnal variation of recurrent febrile seizures is with new ideas.
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Affiliation(s)
- Lingling Shao
- The Department of Pediatric Ward, Zhoushan Women and Children Hospital, No. 238 Renmin North Road, Dinghai District, Zhoushan, 316000, Zhejiang, China
| | - Youna Yu
- The Department of Pediatric Ward, Zhoushan Women and Children Hospital, No. 238 Renmin North Road, Dinghai District, Zhoushan, 316000, Zhejiang, China.
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Wang J, Chen W, Lai Y. Comprehensive nursing program for children with epilepsy: A randomized controlled trial. Niger J Clin Pract 2023; 26:1498-1504. [PMID: 37929526 DOI: 10.4103/njcp.njcp_93_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Background Epilepsy is a relatively common childhood neurological disease. Children with epilepsy need to take precautions to minimize seizure damage in order to adapt to seizures and manage them. Aim The current study aimed to evaluate the feasibility and effects of a comprehensive nursing program for children with epilepsy to reduce children's symptoms of epilepsy. Subject and Methods Participants were children suffering from epilepsy between 2019 and 2021 at Ningbo Women and Children's Hospital. Seventy children were included in a randomized controlled trial with a comprehensive nursing group (CNG) and an active control group (ACG). Measurements were assessed pre- and post-intervention and at a one- and three-month follow-ups. Children in the CNG learned and practiced the strategies related to the comprehensive nursing intervention. The outcomes were anxiety and depression. Results The results showed that anxiety and depression scores were significantly lower in the CNG than the ACG at 1 and 3 months after intervention (P < 0.05). According to the feasibility results, whereas most participants believed that the program was informative and meaningful, a minority reported that it was time-consuming. Conclusion The intervention has the potential to support children with epilepsy. The program is easily accessible, cost-effective and could be implemented in epilepsy care rehabilitation.
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Affiliation(s)
- J Wang
- Department of Pediatrics, Ningbo Women and Children's Hospital, Ningbo, PR China
| | - W Chen
- Department of Urology, Ningbo Urologic and Nephrotic Hospital, Ningbo, PR China
| | - Y Lai
- Department of Pediatrics, Ningbo Women and Children's Hospital, Ningbo, PR China
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Gould L, Delavale V, Plovnick C, Wisniewski T, Devinsky O. Are brief febrile seizures benign? A systematic review and narrative synthesis. Epilepsia 2023; 64:2539-2549. [PMID: 37466925 DOI: 10.1111/epi.17720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 07/20/2023]
Abstract
Febrile seizures affect 2%-5% of U.S. children and are considered benign although associated with an increased risk of epilepsy and, rarely, with sudden unexplained death. We compared rates of mortality, neurodevelopmental disorders, and neuropathology in young children with simple and complex febrile seizures to healthy controls. We systematically reviewed studies of 3- to 72-month-old children with simple or complex febrile seizures ≤30 min. We searched studies with outcome measures on mortality, neurodevelopment, or neuropathology through July 18, 2022. Bias risk was assessed per study design. Each outcome measure was stratified by study design. PROSPERO registration is CRD42022361645. Twenty-six studies met criteria reporting mortality (11), neurodevelopment (11), and neuropathology (13), including 2665 children with febrile seizures and 1206 seizure-free controls. Study designs varied: 15 cohort, 2 cross-sectional, 3 case-control, 5 series, and 1 case report. Mortality outcomes showed stark contrasts. Six cohort studies following children after febrile seizure (n = 1348) reported no deaths, whereas four child death series and 1 case report identified 24.1% (108/449) deaths associated with simple (n = 104) and complex (n = 3) febrile seizures ≤30 min. Minor hippocampal histopathological anomalies were common in sudden deaths with or without febrile seizure history. Most electroencephalography (EEG) studies were normal. Neuroimaging studies suggested increased right hippocampal volumes. When present, neurodevelopmental problems usually preexisted febrile-seizure onset. Risk bias was medium or high in 95% (18/19) of cohort and case-control studies vs medium to low across remaining study designs. Research on outcomes after simple or brief complex febrile seizures is limited. Cohort studies suffered from inadequate sample size, bias risk, and limited follow-up durations to make valid conclusions on mortality, neurodevelopment, and neuropathology. Sudden death registries, focused on a very small percentage of all cases, strongly suggest that simple febrile seizures are associated with increased mortality. Although most children with febrile seizures have favorable outcomes, longer-term prospective studies are needed.
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Affiliation(s)
- Laura Gould
- Comprehensive Epilepsy Center, NYU Langone Health, New York, New York, USA
- Department of Neurology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
| | - Victoria Delavale
- Comprehensive Epilepsy Center, NYU Langone Health, New York, New York, USA
- Department of Neurology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
| | - Caitlin Plovnick
- Health Sciences Library, NYU Grossman School of Medicine, New York, New York, USA
| | - Thomas Wisniewski
- Department of Neurology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
- Department of Pathology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
- Center for Cognitive Neurology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
- Department of Psychiatry, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, NYU Langone Health, New York, New York, USA
- Department of Neurology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
- Department of Psychiatry, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
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Latimer D, Le D, Falgoust E, Ingraffia P, Abd-Elsayed A, Cornett EM, Singh R, Choi J, Varrassi G, Kaye AM, Kaye AD, Ganti L. Brivaracetam to Treat Partial Onset Seizures in Adults. Health Psychol Res 2023; 10:56782. [PMID: 36726475 PMCID: PMC9886169 DOI: 10.52965/001c.56782] [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: 01/30/2023] Open
Abstract
Purpose of Review Seizures are a hyperexcitable, and hypersynchronous imbalance between excitatory and inhibitory factors (E/I imbalance) in neurotransmission, and epilepsy is the recurrent manifestation of seizures within a reasonable time frame and without being attributable to a reversible cause. Brivaracetam is a derivative of the antiepileptic agent, levetiracetam, that is used as adjuvant therapy for focal onset seizures. It was approved by the FDA in 2016 and has shown promising results with minimal adverse effect reactions in clinical trials. Recent Findings Brivaracetam has been used in multiple clinical trials at various dosages in adults that have partial-onset seizures refractory to conventional treatment. A meta-analysis in 2016 showed that brivaracetam as adjunctive therapy was statically significant in its reduction of adults with drug-refractory seizure frequency.1 The most commonly reported adverse effects that patients who were taking brivaracetam experienced were somnolence, headache, and dizziness. Further studies are necessary to conclude long term efficacy and safety profile of brivaracetam. Conclusion The treatment of epilepsy with pharmacologic agents is a difficult task due to balancing the efficacy of the drug with the side effect profile that will allow for the best quality of life for the patient. There are approximately 30 antiepileptic agents for clinicians to choose from. Brivaracetam is a novel antiepileptic agent that was approved for use by the FDA in 2016 and is showing promising results as monotherapy and adjunctive therapy in individuals with drug-refractory focal seizures while minimizing adverse drug reactions.
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Affiliation(s)
- Dustin Latimer
- Department of Psychiatry and Behavioral MedicineLouisiana State University Health Science Center, Baton Rouge, LA
| | - David Le
- Louisiana State University New Orleans School of Medicine, New Orleans, LA
| | - Evan Falgoust
- Louisiana State University Shreveport School of Medicine, Shreveport, LA
| | - Patrick Ingraffia
- Louisiana State University Shreveport School of Medicine, Shreveport, LA
| | - Alaa Abd-Elsayed
- Department of AnesthesiologyUniversity of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Elyse M. Cornett
- Department of AnesthesiologyLouisiana State University Shreveport, Shreveport, LA
| | - Rupin Singh
- University of Central Florida College of Medicine, Orlando, FL and HCA Osceola Hospital, Kissimmee, FL
| | - JooHee Choi
- Georgetown University School of Medicine, Washington, DC
| | | | - Adam M. Kaye
- Pharmacy PracticeThomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA
| | - Alan D. Kaye
- Department of AnesthesiologyLouisiana State University Shreveport, Shreveport, LA
| | - Latha Ganti
- University of Central Florida College of Medicine, Orlando, FL and HCA Osceola Hospital, Kissimmee, FL
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Ulusoy E, Uysal Ateş Ş, Çitlenbik H, Öztürk A, Şık N, Arslan G, Yılmaz D, Yiş U, Hız S, Duman M. What is the safe observation period for seizure recurrence in pediatric emergency departments? Epilepsy Behav 2023; 139:109049. [PMID: 36603346 DOI: 10.1016/j.yebeh.2022.109049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Afebrile seizures are the common causes of emergency department (ED) admissions in childhood, and there is limited data on the observation period in emergency service follow-up of these patients in terms of seizure recurrence in the literature. This study aims to determine the seizure recurrence time in afebrile seizures and the risk factors that determine it. METHODS Patients aged between 1 month and 18 years with afebrile seizures were included in the study. Seizure recurrence times, demographic data, diagnosis of epilepsy, use of antiseizure medications, Electroencephalography (EEG) and imaging results, structural abnormalities, hospitalizations, and treatments were recorded. RESULTS The median age of 623 patients included in the study was 42 months (16.0-94.0 months) and 59.9% were male. Epilepsy was diagnosed in 372 (59.7%) of the patients. Short-acting benzodiazepine was administered in 249 of the cases. The mean observation time of the patients was 36 hours (24-98 hours). Electroencephalography (EEG) was applied in 437 (70.1%) of the patients and abnormality was detected in 53.5%. Seizure recurrence was observed in 149 patients (23.9%). The median time of seizure recurrence was 1.0 hour (0.5-4.0 hours). Eighty-six percent of the seizure recurrences (n = 129) occurred within the first six hours and 95.3% (n = 142) within the first 12 hours. Risk factors included a history of febrile seizures (p = 0.001, OR = 2.7), not receiving short-acting benzodiazepine therapy (p = 0.026, OR 1.7), previous structural abnormalities (p = 0.018, OR 1.8), and cluster seizures (p = 0.001, OR 6.7) for all patients and also EEG abnormalities in pediatric ED for first seizure (p = 0.012, OR 2.4). CONCLUSION Patients with a history of febrile seizure, previous structural abnormalities, cluster seizures, EEG abnormalities in pediatric ED, and patients who didn't receive BZD treatment were at risk for seizure recurrence in the early period. Since most seizure recurrences occur within the first 6 hours, this period is the most critical time for recurrence risk.
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Affiliation(s)
- Emel Ulusoy
- Dokuz Eylul University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency Care, Izmir, Turkey
| | - Şebnem Uysal Ateş
- Dokuz Eylul University, Faculty of Medicine, Department of Pediatrics, Izmir, Turkey
| | - Hale Çitlenbik
- Dokuz Eylul University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency Care, Izmir, Turkey
| | - Ali Öztürk
- Dokuz Eylul University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency Care, Izmir, Turkey
| | - Nihan Şık
- Dokuz Eylul University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency Care, Izmir, Turkey
| | - Gazi Arslan
- Dokuz Eylul University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Intensive Care Unit, Izmir, Turkey
| | - Durgül Yılmaz
- Dokuz Eylul University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency Care, Izmir, Turkey
| | - Uluç Yiş
- Dokuz Eylul University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Neurology, Izmir, Turkey
| | - Semra Hız
- Dokuz Eylul University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Neurology, Izmir, Turkey
| | - Murat Duman
- Dokuz Eylul University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency Care, Izmir, Turkey.
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Woo S, Nah S, Kim M, Kim S, Lee D, Moon J, Han S. Risk of Epilepsy in Children Presenting to Emergency Departments with Their First Afebrile Seizure: A Retrospective Multicenter Study. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9111741. [PMID: 36421191 PMCID: PMC9689254 DOI: 10.3390/children9111741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022]
Abstract
Seizure is one of the most common neurologic disorders in pediatric emergency department visits. Early detection of epilepsy development in children with afebrile seizures is important. We identified predictors of epilepsy development in children with their first afebrile seizure. In this retrospective multicenter study, we enrolled pediatric patients aged 1 month to 18 years who presented with afebrile seizures at the emergency department from January 2017 to December 2020. Multivariable logistic regression analysis was performed to identify factors associated with epilepsy development. A total of 417 pediatric patients were enrolled, 161 (38.6%) of whom developed epilepsy. From the multivariable logistic regression analysis, older age at onset (2−5 years, odds ratio [OR] 2.611, p = 0.010; 11−15 years, OR 3.138, p = 0.003; 16−18 years, OR 4.292, p = 0.002), longer seizure duration of more than 10 min (OR 4.869, p = 0.006), two or more seizures (OR 2.378, p = 0.004), lethargy (OR 2.341, p = 0.021), and a lactate level > 2.27 mg/dL (OR 4.205, p < 0.001) were significant predictors for the development of epilepsy in children experiencing their first afebrile seizure.
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Affiliation(s)
- Seungho Woo
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Korea
| | - Sangun Nah
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Korea
| | - Minsol Kim
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Korea
| | - Sangil Kim
- Department of Emergency Medicine, Soonchunhyang University Seoul Hospital, Seoul 04401, Korea
| | - Dongwook Lee
- Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan 31151, Korea
| | - Jieun Moon
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Korea
| | - Sangsoo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Korea
- Correspondence:
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10
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Evaluation and Management of New Onset and Breakthrough Seizures in Adults in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-022-00253-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Aksu Uzunhan T, Kaçar A, Mısırlı Özdemir E, Yapıcı Ö. First afebrile seizures: Clinical and radiological view with emergent testing. Pediatr Int 2022; 64:e15089. [PMID: 34882919 DOI: 10.1111/ped.15089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 11/04/2021] [Accepted: 12/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The first afebrile seizures in children are an important and common reason for emergency department admissions. We aim to examine the presentation, laboratory/neurodiagnostic investigation, and emergency management of children with first afebrile seizures. METHODS The retrospective study included 333 patients aged 1 month to 18 years admitted with a first afebrile seizure to the pediatric emergency department of Prof. Dr. Cemil Taşcıoğlu City Hospital between January 2017 and January 2020. Age, gender, seizure duration and type, treatments for seizures, laboratory, neurophysiological, and radiological investigations, ward or intensive care unit hospitalizations, and antiepileptic drugs on discharge were recorded. RESULTS The average age of the patients was 81.6 ± 62.9 months; 187 (56.2%) were male and 146 (43.8%) were female. Two hundred and sixty-one (78.4%) patients had only one seizure. In 45 (13.5%) of the patients, the seizure recurred in the emergency department. Hypoglycemia, hyponatremia, and hypocalcemia were detected in 13 (3.9%) patients. Patients with clinically significant cranial computed tomography results were at an increased risk for seizures lasting longer than 5 min. Patients with focal seizures had more recurrences, were given more antiepileptic drugs during the emergency, had better known etiology, more intensive care unit hospitalization, and greater post-discharge antiepileptic drug prescription. CONCLUSIONS Biochemical abnormalities remain in the background in the etiology of afebrile seizures. Patients with abnormal neuroimaging on cranial tomography tended to have longer seizures. Patients with focal seizures followed a more complicated course as they had more recurrences and more hospitalization in the intensive care unit.
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Affiliation(s)
- Tuğçe Aksu Uzunhan
- Department of Pediatric Neurology, Prof. Dr. Cemil Taşcıoğlu City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Alper Kaçar
- Department of Pediatrics, Prof. Dr. Cemil Taşcıoğlu City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Ebru Mısırlı Özdemir
- Department of Pediatrics, Prof. Dr. Cemil Taşcıoğlu City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Özge Yapıcı
- Department of Pediatric Radiology, Prof. Dr. Cemil Taşcıoğlu City Hospital, University of Health Sciences, İstanbul, Turkey
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Lu J, Xia H, Li W, Shen X, Guo H, Zhang J, Fan X. Genetic Polymorphism of GABRG2 rs211037 is Associated with Drug Response and Adverse Drug Reactions to Valproic Acid in Chinese Southern Children with Epilepsy. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2021; 14:1141-1150. [PMID: 34552348 PMCID: PMC8450188 DOI: 10.2147/pgpm.s329594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/02/2021] [Indexed: 12/25/2022]
Abstract
Background Valproic acid (VPA) is recommended as a first-line treatment for children with epilepsy. GABRG2 polymorphism is found to be associated with epilepsy susceptibility and therapeutic response of anti-seizure medications (ASM); however, the role of GABRG2 in VPA treatment still remains unknown. Objective The purpose of this study was to explore the association of GABRG2 gene polymorphism with the drug response and adverse drug reactions (ADRs) related to VPA. Methods A retrospective study including 96 Chinese children with epilepsy treated by VPA was carried out. The ADRs were collected during VPA therapy and GABRG2 rs211037 in enrolled patients was genotyped using Sequenom MassArray system. A network pharmacological analysis involved protein–protein interaction and enrichment analysis was constructed to investigate the potential targets and pathways of GABRG2 on VPA-related ADRs. Results Among 96 patients, 41 individuals were defined as seizure together with 49 patients with seizure-free and 6 patients unclassified. Carriers of homozygote GABRG2 rs211037 CC genotype exhibited seizure-free to VPA (P = 0.042), whereas those with CT genotype showed seizure. Furthermore, CC genotype had predisposition to digestive ADRs (P = 0.037) but was a protective factor for VPA-associated weight gain (P = 0.013). Ten key genes related to digestive ADRs and weight gain induced by VPA were identified by network pharmacological analysis and mainly involved in “GABAergic synaptic signaling”, “GABA receptor signaling”, and “taste transduction” pathways/processes through enrichment analysis. Conclusion This study revealed that GABRG2 variation exerted a predictable role in the efficacy and safety of VPA treatment for Chinese children with epilepsy.
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Affiliation(s)
- Jieluan Lu
- Department of Clinical Pharmacology, College of Pharmacy, Jinan University, Guangzhou, 510632, People's Republic of China
| | - Hanbing Xia
- Department of Pharmacy, Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, People's Republic of China
| | - Wenzhou Li
- Department of Pharmacy, Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, People's Republic of China
| | - Xianhuan Shen
- Department of Clinical Pharmacology, College of Pharmacy, Jinan University, Guangzhou, 510632, People's Republic of China
| | - Huijuan Guo
- Department of Pharmacy, Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, People's Republic of China
| | - Jianping Zhang
- Department of Clinical Pharmacology, College of Pharmacy, Jinan University, Guangzhou, 510632, People's Republic of China
| | - Xiaomei Fan
- Department of Pharmacy, Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, People's Republic of China
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Risk factors affecting seizure recurrence in childhood epilepsy during short-term follow-up. Childs Nerv Syst 2021; 37:2857-2863. [PMID: 34050392 DOI: 10.1007/s00381-021-05227-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/23/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The aim of this study is to examine the factors affecting seizure recurrence in pediatric patients diagnosed with epilepsy. METHODS Three hundred patients presenting to the pediatric neurology clinic between 2015 and 2018 and diagnosed with epilepsy and treated with single antiseizure drug were included in the study. Medical histories and clinical and laboratory findings were retrieved retrospectively from the hospital data system. The combined and adjusted effects of risk factors on seizure recurrence were evaluated using multivariate binary logistic regression analysis. RESULTS Boys had a higher rate of seizure recurrence than girls. Seizure recurrence was also higher in patients with abnormal neurological examinations at the time of diagnosis compared to those with normal neurological examinations. Seizure recurrence was significantly higher in patients with global growth retardation. Epilepsy patients with abnormal MRI findings also had a higher rate of seizure recurrence than patients with normal neuroimaging findings. In addition, seizure recurrence was significantly higher in epilepsy patients with comorbidities such as cerebral palsy and autism spectrum disorders compared to patients without comorbidities. No significant association was observed between seizure recurrence and the first drug, perinatal asphyxia history, localization of epileptiform discharges on EEG, family history of epilepsy, family history of febrile seizures, history of stay in the neonatal intensive care unit during the perinatal period, or preterm delivery. CONCLUSION Abnormal neurological examination, abnormal neuroimaging and accompanying comorbidities, and global growth retardation at the time of diagnosis are important factors affecting seizure recurrence in pediatric patients with epilepsy.
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Predictors of seizure recurrence in emergency department pediatric patients with first-onset afebrile seizure: A retrospective observational study. Am J Emerg Med 2021; 50:316-321. [PMID: 34428729 DOI: 10.1016/j.ajem.2021.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/27/2021] [Accepted: 08/13/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The primary goals of emergency department (ED) clinicians when dealing with a pediatric patient experiencing a seizure are to control the seizure and prevent seizure-related complications. After stabilizing the patient, the clinician should determine whether the patient is likely to have recurrent seizures that may need treatment such as antiepileptic drugs (AEDs). The early identification of pediatric seizure patients at high risk for recurrence can be of great help in consulting with their parents. This study aimed to identify predictors of seizure recurrence in pediatric patients who visited the ED for first-onset afebrile seizure. METHODS This retrospective study was conducted with pediatric patients aged 1 month to 18 years who visited our ED for afebrile seizure from January 2016 to March 2020. Children with a known seizure disorder, known underlying genetic or metabolic disorder, or acute trauma history, and those lost to follow-up were excluded. Multivariable logistic regression analysis was performed to identify factors associated with seizure recurrence. RESULTS A total of 253 pediatric patients were included in the study. Seizure recurrence was observed in 117 patients (46.3%). From the multivariable logistic regression analysis, older age at onset (11-15 years, odds ratio [OR] 5.781, p = 0.001; 16-18 years, OR 6.223, p = 0.002), a longer seizure duration (1-5 min, OR 3.043, p = 0.002; 6-10 min, OR 5.629, p = 0.002; >10 min, OR 8.882, p = 0.002), blood pH under 7.2 (OR 8.308, p = 0.015), and a glucose level over 144 mg/dL (OR 6.408, p = 0.030) were significantly associated with seizure recurrence. The area under the receiver operating characteristic curve for the multivariable logistic regression analysis was 0.774. CONCLUSION Age at onset ≥11 years, a longer seizure duration, acidosis, and hyperglycemia were predictors of seizure recurrence in children who had experienced first-onset afebrile seizure.
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Cavallaro SC, Monuteaux MC, Chaudhari PP, Michelson KA. Use of Neuroimaging for Children With Seizure in General and Pediatric Emergency Departments. J Emerg Med 2021; 60:478-484. [PMID: 33419652 PMCID: PMC8084929 DOI: 10.1016/j.jemermed.2020.10.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/07/2020] [Accepted: 10/19/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Seizure is a common reason for children to visit the emergency department (ED). Pediatric and general EDs may obtain computed tomography (CT) scans of the head for seizure at different rates. OBJECTIVE To compare rates of head CT for pediatric seizure between general and pediatric EDs. METHODS This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey for patients <21 years of age presenting to an ED with a chief complaint or diagnosis of seizure between 2006 to 2017. Of these patients, we compared head CT use between general and pediatric EDs among patients with fever, trauma, and co-diagnosis of epilepsy using univariable risk differences and in a multivariable logistic regression model. RESULTS More than 5 (5.4) million (78.8%) and 1.5 million (21.2%) pediatric patients with seizure presented to general and pediatric EDs, respectively. Of those, 22.4% (1.21 million) and 13.2% (192,357) underwent CT scans of the head, respectively, a risk difference of 9.2% (95% confidence interval [CI] 2.3-16.1). General EDs obtained CT scans of the head more often in patients with epilepsy (risk difference 17.9% [95% CI 4.0-31.9]), without fever (12.2% [95% CI 3.1-21.4]), and without trauma (10.6% [95% CI 4.4-16.8]). Presenting to a general ED, being afebrile, or having trauma were associated with head CT with adjusted odds ratios of 1.7 (95% CI 1.0-3.2), 4.9 (95% CI 2.6-9.2), and 2.0 (95% CI 1.2-3.4), respectively. Age, gender, and epilepsy were not associated with head CT among all patients with seizure. CONCLUSIONS Children with seizure are more likely to undergo CT scans of the head at general EDs compared with pediatric EDs.
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Affiliation(s)
- Sarah C Cavallaro
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, 300 Longwood Avenue, MA, 02115
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, 300 Longwood Avenue, MA, 02115
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles and Keck School of Medicine of the University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, 300 Longwood Avenue, MA, 02115
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Choi YJ, Han MY, Lee EH. Children with transient loss of consciousness: Clinical characteristics and the effectiveness of diagnostic tests. Pediatr Neonatol 2020; 61:584-591. [PMID: 32680815 DOI: 10.1016/j.pedneo.2020.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/16/2020] [Accepted: 06/15/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Transient loss of consciousness (TLOC) is common among children and adolescents. The aims of this study were to identify clinical differences between patients with vasovagal syncope and those with epileptic seizures, which account for a large proportion of TLOC cases, and to evaluate the effectiveness of various diagnostic tests. METHODS The medical records of 160 children and adolescents with TLOC were analyzed retrospectively, and age, sex, clinical symptoms, and trigger factors were recorded. The cardiological and neurological evaluations performed included electrocardiograms, computed tomography scanning, magnetic resonance imaging, electroencephalograms (EEGs), echocardiograms, and head-up tilt tests (HUTTs). Overall assessments of the 160 patients generated final diagnoses. RESULTS The mean age of patients was 14.6 years old and TLOC occurred more frequently among girls (59.4%). The most common final diagnosis was vasovagal syncope (n = 102, 63.4%), followed by undetermined (n = 21, 13.1%) and epileptic seizures (n = 17, 10.6%). There were many other diagnoses, including cardiogenic syncope (1.3%). Patients diagnosed with vasovagal syncope were much more likely to have dizziness or light-headedness and blurred vision as pre-symptoms (p < 0.05), whereas patients diagnosed with epileptic seizures were more likely to have convulsions as an accompanying sign (p < 0.05). In addition, standing up was the most significant trigger factor for TLOC among those diagnosed with vasovagal syncope (p < 0.05). The sensitivity, specificity, and accuracy of the HUTT for vasovagal syncope were 95.1%, 75.0%, and 91.8%, respectively. Similarly, the sensitivity, specificity, and accuracy of EEGs for epileptic seizures were 80.0%, 70.6%, and 80.0%, respectively. CONCLUSION Vasovagal syncope and epileptic seizures should be considered as possible causes of most cases of TLOC in children and adolescents. An accurate case history and appropriate evaluation are essential for correct diagnoses.
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Affiliation(s)
- Young Ju Choi
- Department of Pediatrics, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Mi Young Han
- Department of Pediatrics, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Eun Hye Lee
- Department of Pediatrics, College of Medicine, Kyung Hee University, Seoul, Republic of Korea.
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Chen H, Chen Y, Zhong JM. Detection and diagnostic value of serum NSE and S100B protein levels in patients with seizures associated with mild gastroenteritis: A retrospective observational study. Medicine (Baltimore) 2020; 99:e23439. [PMID: 33235129 PMCID: PMC7710215 DOI: 10.1097/md.0000000000023439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Benign convulsions with mild gastroenteritis (CwG) and febrile seizures (FS) associated with mild gastroenteritis are 2 different diseases in the spectrum of seizures associated with mild gastroenteritis. However, specific and useful indicators for the identification of the 2 diseases are lacking. A retrospective analysis was performed to compare the serum neuronal-specific enolase (NSE) and S100B protein levels between patients with these 2 diseases to evaluate the value of NSE and S100B for differential diagnosis between these 2 diseases.The clinical data and NSE and S100B protein levels of 81 children with seizure-associated mild gastroenteritis were collected. According to the axillary temperature at the time of convulsions, all patients were classified into an afebrile seizure (AFS) group, hereafter called the CwG group (n = 46), and a febrile seizure group (FS group, n = 35).The serum NSE level was higher in the CwG group than in the FS group (14.046 (11.095, 19.266) pg/ml and 9.034 (7.158, 12.165) pg/ml, respectively, P < .001); however, the serum S100B protein levels in the CwG and the FS group were not significantly different (P > .05). Receiver operating characteristic (ROC) curve analysis showed that the area under the curve (AUC) for NSE was 0.806, P = .000, which was statistically significant. The Youden index was largest (0.605) for a serum NSE cut-off value of 10.460 pg/ml, which yielded a sensitivity and specificity of 89% and 71%, respectively, for prediction of a CwG diagnosis.NSE may contribute to the differential diagnosis of CwG and FS associated with mild gastroenteritis.
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Abbasi A, Kazi G, Siddiqui S, Siddiqi Y. Clinical profile & management of children with seizures presenting to pediatric emergency department: A cross-sectional study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gill D. Dealing with a first seizure: accurate diagnosis and good management. Dev Med Child Neurol 2019; 61:9-10. [PMID: 30294775 DOI: 10.1111/dmcn.14052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Deepak Gill
- TY Nelson Department of Neurology, Kids Neuroscience Centre, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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