Epidemiology of Pediatric Convulsive Status Epilepticus With Fever in the Emergency Department: A Cohort Study of 381 Consecutive Cases

Growth and differentiation factor-15 as a potential prognostic biomarker for status-epilepticus-associated-with-fever: A pilot study

OBJECTIVE

Biomarkers predicting poor outcomes of status-epilepticus-associated-with-fever (SEF) at an early stage may contribute to treatment guidance. However, none have been reported thus far. We investigated the dynamics of serum growth and differentiation factor (GDF)-15 after seizure onset in patients with SEF and determined whether GDF-15 can predict poor outcomes, particularly in the first 6 h after seizure onset.

METHODS

We enrolled 37 pediatric patients with SEF and eight patients with simple febrile seizures (SFS) and collected their blood samples within 24 h of seizure onset and eight febrile control patients between March 1, 2017 and September 30, 2020. All patients were aged ≤15 years.

RESULTS

In the SEF group, the median post-seizure serum GDF-15 values were 1,065 (<6h), 2,720 (6-12 h), and 2,411 (12-24 h) pg/mL. The median serum GDF-15 in the first 6 h was measured in patients with SEF without a significant past medical history (n = 21) and was found to be statistically significantly higher (1,587 pg/mL) than in the febrile control (551 pg/mL) and SFS (411 pg/mL) groups. The median serum GDF-15 was statistically significantly higher in patients with SEF with sequelae (n = 5) and patients with acute encephalopathy with biphasic seizures/reduced diffusion/hemorrhagic shock and encephalopathy syndrome (n = 6) than in patients with SEF without sequelae (n = 16) (15,898 vs 756 pg/mL) and patients with prolonged FS (n = 15) (9,448 vs 796 pg/mL).

CONCLUSIONS

This study demonstrates the dynamics of serum GDF-15 in patients with SEF and indicates the potential of GDF-15 as an early predictor of poor outcomes.

Incidence and risk factors of acute encephalopathy with biphasic seizures in febrile status epilepticus

OBJECTIVE

To clarify the incidence and risk factors of acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) in pediatric patients with febrile status epilepticus (FSE).

METHODS

We retrospectively surveyed patients with FSE (≥20 min and ≥40 min) who were younger than 6 years by mailing a questionnaire to 1123 hospitals in Japan. The survey period was 2 years. We then collected clinical data on patients with prolonged febrile seizures (PFS) ≥40 min and those with AESD, and compared clinical data between the PFS and AESD groups.

RESULTS

The response rate for the primary survey was 42.3%, and 28.0% of hospitals which had applicable cases responded in the secondary survey. The incidence of AESD was 4.3% in patients with FSE ≥20 min and 7.1% in those with FSE ≥40 min. In the second survey, a total of 548 patients had FSE ≥40 min (AESD group, n = 93; PFS group, n = 455). Univariate analysis revealed significant between-group differences in pH, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, creatine kinase, NH₃, procalcitonin (PCT), uric acid, blood urea nitrogen, creatinine (Cr), and lactate. Multivariate analysis using stratified values showed that high PCT was an only risk factor for AESD. A prediction score of ≥3 was indicative of AESD, as determined using the following indexes: HCO3^- < 20 mmol/L (1 point), Cl <100 mEq/L (1 point), Cr ≥0.35 mg/dL (1 point), glucose ≥200 mg/dL (1 point), and PCT ≥1.7 pg/mL (2 points). The scoring system had sensitivity of 84.2% and specificity of 81.0%.

CONCLUSION

Incidence data and prediction scores for AESD will be useful for future intervention trials for AESD.

The Utility of Infectious and Neurodiagnostic Testing in Children With Complex Febrile Seizures Requiring Mechanical Ventilation

A retrospective cohort analysis was performed on 79 consecutive patients between 6 months and 5 years admitted to a tertiary hospital with a diagnosis of complex febrile seizures requiring mechanical ventilation from 2011 to 2017 to determine the utility of infectious and neurologic diagnostics. Intubation was used as a proxy for severity of illness. The overall intensive care unit stay was short (95% intubated <24 hours, 88% admitted <3 days). No life-threatening infections were identified, and none required surgical interventions. Electroencephalogram (EEG) was obtained on 43%, 26% of which were abnormal. Sixty-six percent of patients were discharged on rescue benzodiazepine and 20% with maintenance antiseizure medications. Duration of follow-up averaged 4 years (range 1 month to 9 years); 8 patients (10%) were subsequently diagnosed with epilepsy. Our findings suggest that extensive diagnostic evaluations may not be necessary for children with complex febrile seizures requiring mechanical ventilation although the role of EEG is less understood.

Status Epilepticus in Children

For various reasons, status epilepticus in children is different than in adults. Pediatric specificities include status epilepticus epidemiology, underlying etiologies, pathophysiological mechanisms, and treatment options. Relevant data from the literature are presented for each of them, and questions remaining open for future studies on status epilepticus in childhood are listed.

Recent treatment patterns and variations for pediatric acute encephalopathy in Japan

BACKGROUND

Treatments for pediatric acute encephalopathy are largely empiric with limited evidence to support. This study investigated recent trends in clinical practice patterns for pediatric acute encephalopathy at a national level.

METHOD

Discharge records were extracted for children with acute encephalopathy for the fiscal years 2010-2015 using a national inpatient database in Japan. We ascertained the secular trends in medications, diagnostic and therapeutic procedures, healthcare costs, in-hospital mortality, and length of hospital stays (LOS), using mixed effect linear or logistic regression models. We also ascertained variations and clustering of the practice patterns across different hospitals using hierarchical cluster analyses.

RESULTS

A total of 4692 eligible inpatients were identified. From 2010 to 2015, we observed increasing trends in hospitalization costs, corticosteroid and edaravone use and a decreasing trend in LOS. Despite changes in treatments, the rates of home respiratory support and in-hospital mortality were constant during the study period. Hierarchical cluster analyses showed that 6 hospital groups showed largely different therapeutic strategies to the same disease regardless of mortality rates. Hospitals with more intensive treatment practices were likely to have higher mortality, while hospitals with less intensive treatment practices were likely to have the lower mortality. However, hospitals in one group (group 1) had less intensive treatment practice even though they had the highest mortality.

CONCLUSIONS

We provided novel insights into the recent trends in treatments for pediatric acute encephalopathy. Therapeutic strategies varied between hospitals, suggesting the importance of pursuing evidence-based treatment strategy and promoting standardized practices to pediatric acute encephalopathy.

Thermoregulation and age

The thermoregulatory functions may vary with age. Thermosensitivity is active in neonates and children; both heat production and heat loss effector mechanisms are functional but easily exhaustable. Proportional and lasting defense against thermal challenges is difficult, and both hypothermia and hyperthermia may easily develop. Febrile or hypothermic responses to infections or endotoxin can also develop, together with confusion. In small children febrile convulsions may be dangerous. In old age the resting body temperature may be lower than in young adults. Further, thermosensitivity decreases, the thresholds for activating skin vasomotor and evaporative responses or metabolism are shifted, and responses to thermal challenges are delayed or insufficient: both hypothermia and hyperthermia may develop easily. Infection-induced fevers are often limited or absent, or replaced by hypothermia. Various types of brain damage may induce special forms of hypothermia, hyperthermia, or severe fever. Impaired mental state often accompanies hypothermia and hyperthermia, and may occasionally be a dominant feature of infection (instead of the most commonly observed fever). Aging brings about a turning point in women's life: the menopause. The well-known influence of regular hormonal cycles on the thermoregulation of a woman of fertile age gives way to menopausal hot flushes caused by estrogen withdrawal. Not all details of this thermoregulatory anomaly are fully understood yet.