A Systematic Review and Clinical Presentation of Central Nervous System Complications of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospitalized Pediatric Patients During the Coronavirus Disease 2019 Pandemic in Israel

BACKGROUND

Coronavirus disease-associated central nervous system complications (CNS-C) in hospitalized children, especially during the Omicron wave, and in comparison with influenza associated CNS-C, are not well understood.

METHODS

The study population included 755 children aged <18 years hospitalized with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at Sheba Medical Center, during March 2020 to July 2022. A comparative cohort consisted of 314 pediatric patients with influenza during the 2018-2019 and 2019-2020 influenza seasons.

RESULTS

Overall, 5.8% (n = 44) of patients exhibited CNS-C. Seizures at presentation occurred in 33 patients with COVID-19 (4.4%), with 2.6% (n = 20) experiencing nonfebrile seizures, 1.1% (n = 8) febrile seizures, and 0.7% (n = 5) status epilepticus. More patients with CNS-C experienced seizures during the Omicron wave versus the pre-Omicron period (77.8% vs 41.2%, P = 0.03). Fewer patients were admitted to the intensive care unit in the Omicron wave (7.4%) versus prior waves (7.4% vs 41.2%, P = 0.02). Fewer patients with SARS-CoV-2 experienced CNS-C (5.8%) versus patients with influenza (9.9%), P = 0.03. More patients with SARS-CoV-2 experienced nonfebrile seizures (2.6% vs 0.6%, P = 0.06), whereas more patients with influenza experienced febrile seizures (7.3% vs 1.1%, P < 0.01).

CONCLUSIONS

The Omicron wave was characterized by more seizures and fewer intensive-care-unit admissions than previous waves. Pediatric patients with SARS-CoV-2 experienced fewer CNS-C and more nonfebrile seizures compared with patients with influenza.

Developmental patterning function of GNOM ARF-GEF mediated from the cell periphery

The GNOM (GN) Guanine nucleotide Exchange Factor for ARF small GTPases (ARF-GEF) is among the best studied trafficking regulators in plants, playing crucial and unique developmental roles in patterning and polarity. The current models place GN at the Golgi apparatus (GA), where it mediates secretion/recycling, and at the plasma membrane (PM) presumably contributing to clathrin-mediated endocytosis (CME). The mechanistic basis of the developmental function of GN, distinct from the other ARF-GEFs including its closest homologue GNOM-LIKE1 (GNL1), remains elusive. Insights from this study largely extend the current notions of GN function. We show that GN, but not GNL1, localizes to the cell periphery at long-lived structures distinct from clathrin-coated pits, while CME and secretion proceed normally in gn knockouts. The functional GN mutant variant GNfewerroots, absent from the GA, suggests that the cell periphery is the major site of GN action responsible for its developmental function. Following inhibition by Brefeldin A, GN, but not GNL1, relocates to the PM likely on exocytic vesicles, suggesting selective molecular associations en route to the cell periphery. A study of GN-GNL1 chimeric ARF-GEFs indicates that all GN domains contribute to the specific GN function in a partially redundant manner. Together, this study offers significant steps toward the elucidation of the mechanism underlying unique cellular and development functions of GNOM.

Video Analyses of Sudden Unexplained Deaths in Toddlers

BACKGROUND AND OBJECTIVES

More than 2,900 US children aged younger than 4 years die from unknown causes each year, accounting for more than 219,000 life years lost annually. They are mostly sleep-related and unwitnessed with unremarkable autopsies, limiting our understanding of death mechanisms. We sought to understand potential mechanisms of death by evaluating videos of sudden deaths in toddlers.

METHODS

In our registry of 301 sudden unexplained child deaths, a series of 7 consecutively enrolled cases with home video recordings of the child's last sleep period were independently assessed by 8 physicians for video quality, movement, and sound.

RESULTS

Four boys and 3 girls (13-27 months at death) with terminal videos shared similar demographic features to the 293 other registry cases without video recordings. Five video recordings were continuous and 2 were triggered by sound or motion. Two lacked audio. All continuous recordings included a terminal convulsive event lasting 8-50 seconds; 4 children survived for >2.5 minutes postconvulsion. Among discontinuous videos, time lapses limited review; 1 suggested a convulsive event. Six were prone with face down, and 1 had autopsy evidence of airway obstruction. Primary cardiac arrhythmias were not supported; all 7 children had normal cardiac pathology and whole-exome sequencing identified no known cardiac disease variants.

DISCUSSION

Audio-visual recordings in 7 toddlers with unexplained sudden deaths strongly implicate that deaths were related to convulsive seizures, suggesting that many unexplained sleep-related deaths may result from seizures.

Functional Characteristics of the Nav1.1 p.Arg1596Cys Mutation Associated with Varying Severity of Epilepsy Phenotypes

Mutations of the SCN1A gene, which encodes the voltage-dependent Na+ channel's α subunit, are associated with diverse epileptic syndromes ranging in severity, even intra-family, from febrile seizures to epileptic encephalopathy. The underlying cause of this variability is unknown, suggesting the involvement of additional factors. The aim of our study was to describe the properties of mutated channels and investigate genetic causes for clinical syndromes' variability in the family of five SCN1A gene p.Arg1596Cys mutation carriers. The analysis of additional genetic factors influencing SCN1A-associated phenotypes was conducted through exome sequencing (WES). To assess the impact of mutations, we used patch clamp analysis of mutated channels expressed in HEK cells and in vivo neural excitability studies (NESs). In cells expressing the mutant channel, sodium currents were reduced. NESs indicated increased excitability of peripheral motor neurons in mutation carriers. WES showed the absence of non-SCA1 pathogenic variants that could be causative of disease in the family. Variants of uncertain significance in three genes, as potential modifiers of the most severe phenotype, were identified. The p.Arg1596Cys substitution inhibits channel function, affecting steady-state inactivation kinetics. Its clinical manifestations involve not only epileptic symptoms but also increased excitability of peripheral motor fibers. The role of Nav1.1 in excitatory neurons cannot be ruled out as a significant factor of the clinical phenotype.

Epilepsy in dystrophinopathies: A retrospective cohort and review of the literature

OBJECTIVE

This study aimed to assess the prevalence and characteristics of epilepsy in dystrophinopathies within a cohort of 142 patients at a tertiary neuromuscular center in Istanbul, Turkey.

METHODS

We recorded the age at seizure onset, seizure type, family history, history of febrile seizures, treatment, and EEG results. Epilepsy was classified according to the latest International League Against Epilepsy (ILAE) classification.

RESULTS

Of the 142 DMD patients, 8 experienced epileptic seizures (5.6 %). The median age of the patients was 11 years (8.0-15.2). The median age for the first DMD symptoms was 24 months (16.5-37.5). All seizures were consistent with generalized tonic-clonic seizures. Three patients are currently on anti-seizure medication.

SIGNIFICANCE

The prevalence of epilepsy in our study (5.6 %) exceeds that of the general pediatric population (0.5-1 %). However, the frequency of febrile seizures in children with dystrophinopathy is similar to that of the general population.

Increased expression of NLRP3 associated with elevated levels of HMGB1 in children with febrile seizures: a case-control study

BACKGROUND

High mobility group box-1 (HMGB1) is an endogenous danger signal that mediates activation of the innate immune response including NLR pyrin domain containing 3 (NLRP3) inflammasome activation and proinflammatory cytokine release. Although HMGB1 and NLRP3 have been implicated in the pathophysiology of seizures, the correlation between HMGB1 and NLRP3 expression has not been determined in children with febrile seizures (FS). To explore the relationship between extra-cellular HMGB1 and NLRP3 in children with FS, we analyzed serum HMGB1, NLRP3, caspase-1, and proinflammatory cytokines in patients with FS.

METHODS

Thirty children with FS and thirty age-matched febrile controls were included in this study. Blood was obtained from the children with FS within 1 h of the time of the seizure; subsequently, the serum contents of HMGB1, NLRP3, caspase-1, interleukin (IL)-1β, interleukin (IL)-6, and tumour necrosis factor-α (TNF-α) were determined by enzyme-linked immunosorbent assay. The Mann‒Whitney U test was used to compare serum cytokine levels between FS patients and controls. Spearman's rank correlation coefficient was calculated to detect significant correlations between cytokine levels.

RESULTS

Serum levels of HMGB1, NLRP3, caspase-1, IL-1β, IL-6, and TNF-α were significantly higher in FS patients than in febrile controls (p < 0.05). Serum levels of HMGB1 were significantly correlated with levels of NLRP3 and caspase-1 (both, p < 0.05). Serum levels of caspase-1 were significantly correlated with levels of IL-1β (p < 0.05). Serum levels of IL-1β were significantly correlated with levels of IL-6 and TNF-α (p < 0.05).

CONCLUSIONS

HMGB1 is up-regulated in the peripheral serum of FS patients, which may be responsible, at least in part, for the increased expression of NLRP3 and Caspase-1. Increased expression of caspase-1 was significantly associated with elevated serum levels of IL-1β. Given that activated Caspase-1 directly regulates the expression of mature IL-1β and positively correlates with activation of the NLRP3 inflammasome, our data suggest that increased levels of peripheral HMGB1 possibly mediate IL-1β secretion through the activation of the NLRP3 inflammasome in children with FS. Thus, both HMGB1 and NLRP3 might be potential targets for preventing or limiting FS.

Mild Neurological Manifestations Associated With Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Hospitalized Children During the Omicron Wave in Singapore: A Retrospective Cohort Review

BACKGROUND

Neurological complications with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) omicron variant have been reported in adults; however, there are little data in the pediatric population. We aimed to report on the prevalence and clinical characteristics of children with neurological symptoms during the SARS-CoV-2 omicron wave.

METHODS

This was a single-center, retrospective cohort review of children (<18 years old) hospitalized for SARS-CoV-2 infection from December 2, 2021, to June 30, 2022.

RESULTS

During the study period, 455 children (mean age 4.8 years, range 0.67 to 18, male 58.9%) were hospitalized with SARS-CoV-2 infection. A total of 108 (23.7%) children experienced neurological symptoms; most common were seizures (62.0%), headaches (32.4%) and giddiness (14.8%). Seizures included febrile seizures (64.1%), acute symptomatic seizures (17.9%), and breakthrough seizures in known epileptics (17.9%). Children with neurological manifestations were older (7.3 vs 4.0 years, P < 0.00001), more likely to have underlying epilepsy (9.3% vs 1.2%, P = 0.0002) or neurodevelopmental disorders (17.6% vs 1.7%, P < 0.00001), and presented earlier in their illness (2.1 vs 2.8 days, P < 0.00001), compared with those without neurological manifestations. Neurological symptoms fully resolved in all but one patient at discharge. There were no mortalities and no difference in duration of hospitalization (3.1 vs 3.7 days, P = 0.5) between the groups.

CONCLUSIONS

One in four hospitalized children with SARS-CoV-2 infection when omicron variant was dominant experienced mild neurological symptoms. Overall risk factors for neurological symptoms associated with SARS-CoV-2 included older age, pre-existing febrile seizures/epilepsy and neurodevelopmental disorders.

A nationwide survey of adenovirus-associated encephalitis/encephalopathy in Japan

BACKGROUND

Adenovirus is a major pathogen causing febrile illness among children. It may also cause acute encephalitis/encephalopathy. This study aimed to elucidate the clinical features of adenovirus-associated encephalitis/encephalopathy (AdVE) among children in Japan.

METHODS

A nationwide survey of children with AdVE was conducted. An initial survey was distributed among pediatricians to obtain information about children with AdVE treated between January 2014 and March 2019. A second survey was used to obtain the clinical information of children with AdVE from hospitals that responded to the initial survey and those identified from a literature search of the reported cases. We collected demographic data and information about symptoms of infection, neurological symptoms, laboratory parameters, treatment, and outcomes. Outcomes were determined using the Pediatric Cerebral Performance Category Score.

RESULTS

Clinical information was available for 23 children with a median age of 39 months. Two had preexisting neurological disorders and six had a history of febrile seizures. The outcome was good in 15 patients and poor in eight patients. Serum lactate dehydrogenase, glucose, and ammonia levels were higher among children with a poor outcome compared to those with a good outcome. Clinically mild encephalitis/encephalopathy with a reversible splenial lesion was the most common type (n = 8), followed by acute encephalopathy with biphasic seizures and late reduced diffusion (n = 7).

CONCLUSION

A prior history of febrile seizures was frequent in children with AdVE. Several different subtypes of acute encephalopathy were seen in children with AdVE, and the outcome was poor in those with acute encephalopathy with biphasic seizures and late reduced diffusion and hemorrhagic shock and encephalopathy syndrome. Elevated lactate dehydrogenase, glucose, and ammonia levels on admission were found to correlate with a poor outcome.

Distinctive Clinico-electrographic and Radiological Profile of Childhood and Adolescent Seizures

AIM

Electroencephalogram (EEG) is specific, but not sensitive, for the diagnosis of epilepsy. This study aimed to correlate the clinico-electrographic and radiological features of seizure disorders in children attending a tertiary care centre in northern India.

METHODS

Children aged between one to 18 years with seizure episodes were included. Clinical details, including historical as well as physical findings, were evaluated along with EEG and neuroimaging (Magnetic resonance imaging). Details were noted on pre-designed proforma. Variables were analysed by using appropriate statistical methods.

RESULTS

A total of 110 children with seizures were enrolled in the study. Male to female ratio was 1.6: 1, and the mean age of the study children was 8 years. The majority of the children were symptomatic for more than one year. The most common seizure type was Generalised Tonic Clonic Seizure (GTCS), and Hypoxic-ischemic Encephalopathy (HIE) sequelae was the most commonly attributed etiology, followed by neurocysticercosis. EEG and neuroimaging findings were found to correlate well with seizure semiology from history. The incidence of febrile seizures was 10% in this study, with nearly three-fourths of them being simple febrile seizures.

CONCLUSION

Microcephaly and developmental delay were the most distinctive clinical correlates in children with seizures. There was a fair agreement between the types of seizures described in history and depicted on EEG with Cohen's kappa of 0.4. Also, there was a significant association between the type of seizures on EEG and the duration of symptoms.

Distinct manifestations and potential mechanisms of seizures due to cortical versus white matter injury in children

PURPOSE

To study seizure manifestations and outcomes in children with cortical versus white matter injury, differences potentially explaining variability of epilepsy in children with cerebral palsy.

METHODS

In this population-based retrospective cohort study, MRIs of children with cerebral palsy due to ischemia or haemorrhage were classified according to presence or absence of cortical injury. MRI findings were then correlated with history of neonatal seizures, seizures during childhood, epilepsy syndromes, and seizure outcomes.

RESULTS

Of 256 children studied, neonatal seizures occurred in 57 and seizures during childhood occurred in 93. Children with neonatal seizures were more likely to develop seizures during childhood, mostly those with cortical injury. Cortical injury was more strongly associated with (1) developing seizures during childhood, (2) more severe epilepsy syndromes (infantile spasms syndrome, focal epilepsy, Lennox-Gastaut syndrome), and (3) less likelihood of reaching > 2 years without seizures at last follow-up, compared to children without cortical injury. Children without cortical injury, mainly those with white matter injury, were less likely to develop neonatal seizures and seizures during childhood, and when they did, epilepsy syndromes were more commonly febrile seizures and self-limited focal epilepsies of childhood, with most achieving > 2 years without seizures at last follow-up. The presence of cortical injury also influenced seizure occurrence, severity, and outcome within the different predominant injury patterns of the MRI Classification System in cerebral palsy, most notably white matter injury.

CONCLUSIONS

Epileptogenesis is understood with cortical injury but not well with white matter injury, the latter potentially related to altered postnatal white matter development or myelination leading to apoptosis, abnormal synaptogenesis or altered thalamic connectivity of cortical neurons. These findings, and the potential mechanisms discussed, likely explain the variability of epilepsy in children with cerebral palsy and epilepsy following early-life brain injury in general.

Alterations in Rat Hippocampal Glutamatergic System Properties after Prolonged Febrile Seizures

Febrile seizures during early childhood may result in central nervous system developmental disorders. However, the specific mechanisms behind the impact of febrile seizures on the developing brain are not well understood. To address this gap in knowledge, we employed a hyperthermic model of febrile seizures in 10-day-old rats and tracked their development over two months. Our objective was to determine the degree to which the properties of the hippocampal glutamatergic system are modified. We analyzed whether pyramidal glutamatergic neurons in the hippocampus die after febrile seizures. Our findings indicate that there is a reduction in the number of neurons in various regions of the hippocampus in the first two days after seizures. The CA1 field showed the greatest susceptibility, and the reduction in the number of neurons in post-FS rats in this area appeared to be long-lasting. Electrophysiological studies indicate that febrile seizures cause a reduction in glutamatergic transmission, leading to decreased local field potential amplitude. This impairment could be attributable to diminished glutamate release probability as evidenced by decreases in the frequency of miniature excitatory postsynaptic currents and increases in the paired-pulse ratio of synaptic responses. We also found higher threshold current causing hind limb extension in the maximal electroshock seizure threshold test of rats 2 months after febrile seizures compared to the control animals. Our research suggests that febrile seizures can impair glutamatergic transmission, which may protect against future seizures.

Determining the Role of Immunoglobulin Levels in Children with Febrile Seizures

Background

Febrile seizures are the most common form of convulsive disorder in childhood. The mechanisms underlying the pathogenesis of febrile seizure remain unclear.

Objective

The aim of this study was to assess the immunoglobulin (IG) sub-group levels in children with febrile seizures.

Methods and Material

The patients with a diagnosis of febrile seizure with an age range of 1-7 years who attended the clinic were included in the study. Neurologically normal and age- and sex-matched children with no history of febrile seizures were considered as controls.

Results

A total of 64 patients and 100 control subjects participated in this study. There were no significant inter-group differences in terms of sex and age of the participants (p >.05). There was no statistical difference between case and control groups for serum lymphocyte count, IgA, IgG, IgM, IgE levels, and anti-HB response (p >.05).

Conclusion

Our study demonstrated that there is no difference in humoral immunity between children with febrile seizures and control subjects with the same age range.

The clinical spectrum associated with ATP1A2 variants in Chinese pediatric patients

PURPOSE

To evaluate the clinical spectrum associated with ATP1A2 variants in Chinese children with hemiplegia, migraines, encephalopathy or seizures.

METHODS

Sixteen children (12 males and 4 females), including ten patients with ATP1A2 variants whose cases had been published previously, were identified using next-generation sequencing.

RESULTS

Fifteen patients had FHM2 (familial hemiplegic migraine type 2), including three who had AHC (alternating hemiplegia of childhood) and one who had drug-resistant focal epilepsy. Thirteen patients had DD (developmental delay). The onset of febrile seizures, which occurred between 5 months and 2 years 5 months (median 1 year 3 months) was earlier than the onset of HM (hemiplegic migraine), which occurred between 1 year 5 months and 13 years (median 3 years 11 months). Disturbance of consciousness subsided first, at 40 h to 9 days (median 4.5 days); hemiplegia and aphasia were resolved slowly, taking 30 min to 6 months (median 17.5 days) for the former and 24 h to over 1 year (median 14.5 days) for the latter. Cranial MRI showed edema in the cerebral hemispheres, mainly the left hemisphereacute attacks. All thirteen FHM2 patients recovered to baseline in 30 min to 6 months. Fifteen patients had between 1 and 7 (median 2) total attacks between the baseline and follow-up timepoints. We report twelve missense variants, including a novel variant ATP1A2 variant, p.G855E.

CONCLUSIONS

The known genotypic and phenotypic spectra of Chinese patients with ATP1A2-related disorders were further expanded. Recurrent febrile seizures and DD combined with paroxysmal hemiplegia and encephalopathy should raise the clinical suspicion of FHM2. The avoidance of triggers and thus the prevention of attacks may be the most effective therapy for FHM2.

Evaluation of the feasibility, diagnostic yield, and clinical utility of rapid genome sequencing in infantile epilepsy (Gene-STEPS): an international, multicentre, pilot cohort study

BACKGROUND

Most neonatal and infantile-onset epilepsies have presumed genetic aetiologies, and early genetic diagnoses have the potential to inform clinical management and improve outcomes. We therefore aimed to determine the feasibility, diagnostic yield, and clinical utility of rapid genome sequencing in this population.

METHODS

We conducted an international, multicentre, cohort study (Gene-STEPS), which is a pilot study of the International Precision Child Health Partnership (IPCHiP). IPCHiP is a consortium of four paediatric centres with tertiary-level subspecialty services in Australia, Canada, the UK, and the USA. We recruited infants with new-onset epilepsy or complex febrile seizures from IPCHiP centres, who were younger than 12 months at seizure onset. We excluded infants with simple febrile seizures, acute provoked seizures, known acquired cause, or known genetic cause. Blood samples were collected from probands and available biological parents. Clinical data were collected from medical records, treating clinicians, and parents. Trio genome sequencing was done when both parents were available, and duo or singleton genome sequencing was done when one or neither parent was available. Site-specific protocols were used for DNA extraction and library preparation. Rapid genome sequencing and analysis was done at clinically accredited laboratories, and results were returned to families. We analysed summary statistics for cohort demographic and clinical characteristics and the timing, diagnostic yield, and clinical impact of rapid genome sequencing.

FINDINGS

Between Sept 1, 2021, and Aug 31, 2022, we enrolled 100 infants with new-onset epilepsy, of whom 41 (41%) were girls and 59 (59%) were boys. Median age of seizure onset was 128 days (IQR 46-192). For 43 (43% [binomial distribution 95% CI 33-53]) of 100 infants, we identified genetic diagnoses, with a median time from seizure onset to rapid genome sequencing result of 37 days (IQR 25-59). Genetic diagnosis was associated with neonatal seizure onset versus infantile seizure onset (14 [74%] of 19 vs 29 [36%] of 81; p=0·0027), referral setting (12 [71%] of 17 for intensive care, 19 [44%] of 43 non-intensive care inpatient, and 12 [28%] of 40 outpatient; p=0·0178), and epilepsy syndrome (13 [87%] of 15 for self-limited epilepsies, 18 [35%] of 51 for developmental and epileptic encephalopathies, 12 [35%] of 34 for other syndromes; p=0·001). Rapid genome sequencing revealed genetic heterogeneity, with 34 unique genes or genomic regions implicated. Genetic diagnoses had immediate clinical utility, informing treatment (24 [56%] of 43), additional evaluation (28 [65%]), prognosis (37 [86%]), and recurrence risk counselling (all cases).

INTERPRETATION

Our findings support the feasibility of implementation of rapid genome sequencing in the clinical care of infants with new-onset epilepsy. Longitudinal follow-up is needed to further assess the role of rapid genetic diagnosis in improving clinical, quality-of-life, and economic outcomes.

FUNDING

American Academy of Pediatrics, Boston Children's Hospital Children's Rare Disease Cohorts Initiative, Canadian Institutes of Health Research, Epilepsy Canada, Feiga Bresver Academic Foundation, Great Ormond Street Hospital Charity, Medical Research Council, Murdoch Children's Research Institute, National Institute of Child Health and Human Development, National Institute for Health and Care Research Great Ormond Street Hospital Biomedical Research Centre, One8 Foundation, Ontario Brain Institute, Robinson Family Initiative for Transformational Research, The Royal Children's Hospital Foundation, University of Toronto McLaughlin Centre.

Febrile Seizures Cause a Rapid Depletion of Calcium-Permeable AMPA Receptors at the Synapses of Principal Neurons in the Entorhinal Cortex and Hippocampus of the Rat

Febrile seizures (FSs) are a relatively common early-life condition that can cause CNS developmental disorders, but the specific mechanisms of action of FS are poorly understood. In this work, we used hyperthermia-induced FS in 10-day-old rats. We demonstrated that the efficiency of glutamatergic synaptic transmission decreased rapidly after FS by recording local field potentials. This effect was transient, and after two days there were no differences between control and post-FS groups. During early ontogeny, the proportion of calcium-permeable (CP)-AMPA receptors in the synapses of the principal cortical and hippocampal neurons is high. Therefore, rapid internalization of CP-AMPA receptors may be one of the mechanisms underlying this phenomenon. Using the whole-cell patch-clamp method and the selective CP-AMPA receptor blocker IEM-1460, we tested whether the proportion of CP-AMPA receptors changed. We have demonstrated that FS rapidly reduces synaptic CP-AMPA receptors in both the hippocampus and the entorhinal cortex. This process was accompanied by a sharp decrease in the calcium permeability of the membrane of principal neurons, which we revealed in experiments with kainate-induced cobalt uptake. Our experiments show that FSs cause rapid changes in the function of the glutamatergic system, which may have compensatory effects that prevent excessive excitotoxicity and neuronal death.

[Correlation between serum zinc and brain injury in infants with mild gastroenteritis complicated with benign infantile convulsion and febrile convulsion]

OBJECTIVE

To investigate the association between serum zinc levels and convulsive brain injury in infants with mild gastroenteritis complicated with benign infantile seizures (BICE) and febrile seizures (FC).

METHODS

A case-control study method was conducted. 120 children with mild gastroenteritis and convulsion admitted to the First Affiliated Hospital of Hebei North University from January 2020 to January 2022 were enrolled as the research subjects. They were divided into BICE group and FC group according to the type of convulsion. The serum zinc level, the frequency and duration of convulsion, and the occurrence of convulsive brain injury in the two groups were recorded. Multivariate Logistic regression analysis was used to screen the risk factors for convulsive brain injury. The Spearman correlation method was used to analyze the association between serum zinc levels, clinical characteristics of convulsion and convulsive brain injury.

RESULTS

A total of 120 children were enrolled, of which 81 developed to BICE and 39 developed to FC during hospitalization. The serum zinc level of children in the FC group was significantly lower than that in the BICE group (μmol/L: 39.24±6.50 vs. 48.65±7.21, P < 0.01). In the BICE group and FC group, the serum zinc level in children with more than 2 convulsions was significantly lower than that in the children with one convulsion (μmol/L: 37.65±6.50 vs. 53.17±7.55 in the BICE group, and 30.27±5.58 vs. 44.16±7.57 in the FC group, both P < 0.01). Serum zinc level in children with convulsion duration ≥ 5 minutes was significantly lower than that in the children with convulsion duration < 5 minutes (μmol/L: 38.75±6.74 vs. 51.21±7.58 in the BICE group, and 31.08±5.46 vs. 45.19±7.25 in the FC group, both P < 0.01). Moreover, the serum zinc level of children with different convulsion frequency and duration in the FC group was significantly lower than that in the BICE group (all P < 0.01). Among the 120 children, 9 cases of convulsive brain injury occurred, and the incidence rate was 7.50%. The incidence of convulsive brain injury in the BICE group was 1.23% (1/81), which was significantly lower than 20.51% in the FC group (8/39, P < 0.01). The serum zinc level of children with convulsive brain injury was significantly lower than that of children with non-brain injury (μmol/L: 28.50±5.00 vs. 60.22±7.31, P < 0.01), and the number of convulsion was significantly higher than that of non-cerebral injury (≥ 2 convulsions: 100.00% vs. 1.80%, P < 0.01), and the duration of convulsion in children with brain injury was significantly longer than that of non-brain-injured children (convulsion duration ≥ 5 minutes: 100.00% vs. 11.71%, P < 0.01). Multivariate Logistic regression analysis showed that decreased serum zinc level [odds ratio (OR) = 2.147, 95% confidence interval (95%CI) was 1.354-3.403], increased number of convulsion (OR = 3.452, 95%CI was 1.266-9.417), and prolonged convulsion duration (OR = 3.117, 95%CI was 1.326-7.327) were independent risk factor for convulsive brain injury in children with mild gastroenteritis and convulsion (all P < 0.05). Spearman correlation analysis showed that serum zinc level, convulsion ≥ 2 times, duration of convulsion ≥ 5 minutes and convulsion ≥ 2 times + convulsion duration ≥ 5 minutes were significantly negatively correlated with the occurrence of convulsive brain injury in FC children (r values were -0.546, -0.517, -0.522, and -0.528, all P < 0.01). There was no significant correlation between serum zinc level, convulsion ≥ 2 times, convulsion duration ≥ 5 minutes and convulsion ≥ 2 times+convulsion duration ≥ 5 minutes and convulsive brain injury in BICE children (r values were -0.281, -0.129, -0.201, -0.243, all P > 0.05).

CONCLUSIONS

Serum zinc level is related to the characteristics of convulsive symptoms in children with mild gastroenteritis complicated with FC, and has a strong negative correlation with the occurrence of convulsive brain injury. Active targeted intervention and treatment may help reduce the incidence of brain injury in children.

Serum Neurofilament light chain (NfL) levels in children with and without neurologic diseases

BACKGROUND/OBJECTIVE

Serum neurofilament light chain (sNfL) is a specific biomarker of neuronal damage. Elevated sNfL levels have been reported in numerous neurologic diseases in adults, whereas data on sNfL in the pediatric population are incomplete. The aim of this study was to investigate sNfL levels in children with various acute and chronic neurologic disorders and describe the age dependence of sNfL from infancy to adolescence.

METHODS

The total study cohort of this prospective cross-sectional study consisted of 222 children aged from 0 to 17 years. Patients' clinical data were reviewed and patients were assigned to the following groups: 101 (45.5%) controls, 34 (15.3%) febrile controls, 23 (10.4%) acute neurologic conditions (meningitis, facial nerve palsy, traumatic brain injury, or shunt dysfunction in hydrocephalus), 37 (16.7%) febrile seizures, 6 (2.7%) epileptic seizures, 18 (8.1%) chronic neurologic conditions (autism, cerebral palsy, inborn mitochondrial disorder, intracranial hypertension, spina bifida, or chromosomal abnormalities), and 3 (1.4%) severe systemic disease. sNfL levels were measured using a sensitive single-molecule array assay.

RESULTS

There were no significant differences in sNfL levels between controls, febrile controls, febrile seizures, epileptic seizures, acute neurologic conditions, and chronic neurologic conditions. In children with severe systemic disorders, by far the highest NfL levels were found with an sNfL of 429 pg/ml in a patient with neuroblastoma, 126 pg/ml in a patient with cranial nerve palsy and pharyngeal Burkitt's lymphoma, and 42 pg/ml in a child with renal transplant rejection. The relationship between sNfL and age could be described by a second order polynomial with an R2 of 0.153 with a decrease of sNfL by 3.2% per year from birth to age 12 years and thereafter an increase by 2.7% per year until age 18 years.

CONCLUSIONS

In this study cohort, sNfL levels were not elevated in children with febrile or epileptic seizures, or various other neurologic diseases. Strikingly high sNfL levels were detected in children with oncologic disease or transplant rejection. A biphasic sNfL age-dependency was documented, with highest levels in infancy and late adolescence and the lowest levels in middle school age.

Changes of intestinal flora in children with febrile seizure

Febrile seizure (FS) is a highly recurrent neuro-system disorder in children that affects their nervous system development and quality of life. However, the pathogenesis of febrile seizures remains unclear. Our study aims to investigate the potential differences in the intestinal flora and metabolomics between healthy children and those with FS. By examining the relationship between specific flora and different metabolites, we hope to shed light on the pathogenesis of FS. Fecal specimens were collected from healthy children (n = 15) and children with febrile seizures (n = 15), and 16S rDNA sequencing was conducted to characterize intestinal flora. Subsequently, fecal samples from healthy (n = 6) and febrile seizure children (n = 6) were used to characterize metabolomics using linear discriminant analysis of effect size, orthogonal partial least squares discriminant analysis, Kyoto Encyclopedia of Genes and Genomes (pathway enrichment analysis), and Kyoto encyclopedia of genes and genomes topology analysis. Liquid chromatography-mass spectrometry was used to identify metabolites in the fecal samples. The intestinal microbiome in the febrile seizure children significantly differed from that in the healthy children at the phylum level. Ten differentially accumulated metabolites (xanthosine, (S)-abscisic acid, N-palmitoylglycine, (+/-)-2-(5-methyl-5-vinyl-tetrahydrofuran-2-yl) propionaldehyde, (R)-3-hydroxybutyrylcarnitine, lauroylcarnitine, oleoylethanolamide, tetradecyl carnitine, taurine, and lysoPC [18:1 (9z)/0:0] were considered the potential febrile seizure markers. Three metabolic pathways (taurine metabolism; glycine, serine, and threonine metabolism; and arginine biosynthesis) were found essential in febrile seizure. Bacteroides were significantly correlated with the 4 differential metabolites. Adjusting the balance of intestinal flora may be an effective method for preventing and treating febrile seizures.

Recurrent febrile seizures and serum cytokines: a controlled follow-up study

BACKGROUND

The role of cytokines in the pathogenesis of febrile seizures (FSs) is unclear, and information regarding cytokine production outside of FS episodes is scarce.

METHODS

In our controlled follow-up study of patients with FSs, we compared the levels of 12 serum cytokines after the patients' first FSs, during febrile episodes without FSs, after recurrent FSs, during healthy periods after FSs, and between patients and controls.

RESULTS

Two-hundred fifty-one patients with first FS participated in the study, of whom 17 (mean age 1.6 years, SD 0.7) with recurrent FSs completed the protocol as required by the sample size calculations. The mean IL-1RA level was higher after the first FSs (2580 pg/mL, SD 1516) than during febrile episodes without FSs (1336 pg/mL, SD 1364, P = 0.006) and healthy periods after FSs (474 pg/mL, SD 901, P = 0.001). IL-1RA levels were also higher during first (2580 pg/mL) and recurrent FSs (2666 pg/mL, SD 1747) in comparison with febrile controls (746 pg/mL, SD 551) (P < 0.001 and P = 0.001, respectively), but there was no difference in the IL-1RA between febrile episodes without FSs and febrile controls.

CONCLUSIONS

Patients with FSs produce stronger inflammatory reactions during febrile episodes with FSs compared with febrile episodes without FSs and febrile controls.

IMPACT

In patients with FSs, IL-1RA was higher following first FS than during febrile episodes without FSs and healthy periods after FSs. IL-1RA was higher in patients with FSs following first and recurrent FSs than in febrile controls. There was no significant difference in IL-1RA between febrile episodes of patients without FSs and febrile controls. Using IL-1RA as a surrogate marker of IL-1 axis activity, our results indicate that patients with FSs produced stronger inflammatory reactions during FS episodes but not during other febrile episodes or healthy periods after FSs. Cytokines may play a role in pathogenesis of FSs.

Association between high-mobility group box 1 levels and febrile seizures in children: a systematic review and meta-analysis

The relationship between High-mobility group box 1 (HMGB1) and febrile seizures (FS) in children remains unclear. This study aimed to apply meta-analysis to reveal the correlation between HMGB1 levels and FS in children. Databases including PubMed, EMBASE, Web of science, Cochrane library, CNKI, SinoMed and WanFangData were searched for relevant studies. Pooled standard mean deviation and 95% confidence interval were calculated as effect size since the random-effects model was used when I² > 50%. Meanwhile, between-study heterogeneity was determined by performing subgroup and sensitivity analyses. A total of 9 studies were finally included. Meta-analysis showed that the children with FS had significantly higher HMGB1 levels compared with healthy children and children with fever but no seizures (P<0.05). Additionally, subgroup analysis showed that the HMGB1 level in children with complex FS was higher than those with simple FS (P<0.05), and children with duration >15 min were higher than those with duration ≤15min (P<0.05). There were no statistical differences between children with or without a family history of FS (P>0.05). Finally, children with FS who converted to epilepsy exhibited higher HMGB1 levels than those who did not convert to epilepsy (P<0.05). The level of HMGB1 may be implicated in the prolongation, recurrence and development of FS in children. Thus, it was necessary to evaluate the precise concentrations of HMGB1 in FS patients and to further determine the various activities of HMGB1 during FS by well-designed, large-scale, and case-controlled trials.

Inflammation as a target for the treatment of fever-associated epilepsy in zebrafish larvae

Inflammation is considered to be involved in epileptogenesis. However, the relationship between fever and inflammation as well as the mechanisms of fever in the occurrence and development of childhood epilepsy need further investigation. Here, we described an in vivo model of hyperthermia-induced seizures in zebrafish larvae with pentylenetetrazole (PTZ) exposure. Hyperthermia increased the susceptibility to seizure and the production of pro-inflammatory factors in PTZ-induced zebrafish larvae. As mutations in GABRG2 have been associated with fever-associated epilepsy, we used a Tg(hGABRG2^F343L) zebrafish model expressing mutant human GABRG2(F343L) to further investigate the involvement of inflammation in fever-induced seizures. Our data indicated that hyperthermia also increased the locomotor activity in Tg(hGABRG2^F343L) zebrafish larvae. Although the production of pro-inflammatory factors was upregulated by GABRG2 mutation, hyperthermia did not change the production of pro-inflammatory factors significantly. Lipopolysaccharide (LPS) stimulation was sufficient to increase the locomotor activity in zebrafish larvae, suggesting that inflammation contributed to fever-associated epilepsy. The expression of GABRG2 was increased with PTZ induction, especially at a higher temperature. Moreover, inhibition of inflammation by dexamethasone (DEX) reduced the excitability of zebrafish larvae, especially at a higher temperature. Finally, in vitro experiments proved that LPS stimulation increased the production of IL-1β and IL-6 in GABRG2(F343L) transfected cells. Collectively, our study demonstrated that neuroinflammation was induced in febrile seizures, and the increased expression of IL-1β and IL-6 might be responsible for epileptogenesis. The vicious cycle between fever and inflammation might induce seizure onset, and anti-inflammatory strategies might be a potential treatment for fever-associated epilepsy.

Variances of quantifying of Virchow-Robin spaces detecting the different functional status of glymphatic system in simple febrile seizures affected by seizures duration

The Virchow-Robin spaces (VRs) in the cerebral glymphatic system play a vital role in waste clearance from the brain. Simple febrile seizures (SFS) are a common type of seizures marked by an inappropriate fluid exchange. The mechanism of evident differences in glymphatic function among SFS with varying seizure duration is unknown. Therefore, the goal of this study was to see whether there were any variations in glymphatic function among SFS based on seizures duration. We retrospectively studied 30 children with SFS lasting more than 5 minutes (SFS > 5M), 40 children with SFS lasting 5 minutes or less (SFS ≤ 5M), and 35 healthy controls aged 6 to 60 months who underwent magnetic resonance imaging (MRI). A custom-designed automated method that used T2-weighted imaging (T2WI) to segment the visible VRs. The VRs metrics were measured and compared studied groups. The VRs metrics, seizure duration the time gap between seizure onset and MRI scan were studied as well. VRs counts were lower (P < .001) in the SFS ≤ 5M (445.80 ± 66.10) and the control (430.77 ± 182.55) groups in comparison to SFS > 5M (642.70 ± 100.62). Similar results were found for VRs volume (VRsvol_SFS > 5M, 8514.63 ± 835.33mm3, VRsvol_SFS ≤ 5M, 6390.43 ± 692.74 mm3, VRsvol_control, 6048.37 ± 111.50 mm3; P < .001). However, in the SFS ≤ 5M, VRs measurements were lower than in the SFS > 5M (P < .001). VRs measurements were positively connected with seizure duration and inversely correlated with the course following seizure onset and MRI scan time in both SFS groups. SFS are positively correlated to glymphatic dysfunction since they cause enlarged VRs; additionally, VRs can be used as a biomarker in SFS > 5M and contribute to the mechanism.

Risk Factors of First Episode Simple Febrile Seizures in Children Aged 6 Month to 5 Year: A Case Control Study

OBJECTIVES

To study the risk factors of first episode simple febrile seizures in children.

METHODS

This case control study was conducted at the pediatric department of our tertiary care hospital. Cases were children of age group 6 months to 5 years presenting with first simple febrile seizures (n=214), and Controls were children of same age group presenting with short febrile illness but without any seizures (n=214). Blood investigations were done to diagnose iron deficiency, which was diagnosed by adopting cut off of hemoglobin value <11 g/dL, serum ferritin < 12 ng/mL and red cell distribution width >15%. Other risk factors studied included age, gender, socioeconomic status, prematurity, family history of febrile seizure and epilepsy in first degree relatives, consanguinity, neonatal hospital admissions, day care attendance (for >1 mo), under nutrition, and immunization status of the child. Univariate analysis for crude odds ratio and multivariate analysis (logistic regression) was performed to study the adjusted odds ratio and independent risk factors.

RESULTS

The significant risk factors for first episode simple febrile seizure were iron deficiency [OR (95% CI) 5.78 (3.56-9.38); P=0.001], family history of febrile seizure [OR 4.31 (2.37- 7.83), P<0.001] or epilepsy [OR 4.25(2.21-8.19), P<0.001] in first degree relatives, day care attendance for >1 month [OR 4.81 (2.41-9.59), P<0.001], and prematurity at birth [OR 5.18 (2.48-10.84), P<0.001].

CONCLUSION

Iron deficiency, family history of febrile seizure and epilepsy in first degree relatives, day care attendance and premature birth are the risk factors for first episode simple febrile seizures in children.

Child Neurology: Hemiconvulsion-Hemiplegia-Epilepsy Syndrome in the Setting of COVID-19 Infection and Multisystem Inflammatory Syndrome

Hemiconvulsion-hemiplegia-epilepsy (HHE) syndrome is a rare pediatric epilepsy syndrome characterized by prolonged focal febrile convulsive status epilepticus with unilateral hemispheric cerebral edema, followed by the subsequent development of hemiplegia, global atrophy of the affected hemisphere, and epilepsy. The pathophysiology of HHE syndrome remains poorly understood though is clearly multifactorial. Factors thus far implicated are hyperthermia, proinflammatory state, and cytotoxic edema from prolonged ictal activity. Prognosis is variable, from the resolution of hemiplegia and seizures to permanent hemiparesis and refractory epilepsy. We describe a 2-year-old boy who presented with superrefractory focal status epilepticus in the setting of acute coronavirus infectious disease-2019 (COVID-19) and multisystem inflammatory syndrome in children (MIS-C). He had right-sided hemiplegia on neurologic examination, and an MRI examination of the brain showed left cerebral hemispheric edema consistent with HHE syndrome. Our case represents the first report in the literature on HHE syndrome in the setting of acute COVID-19 and MIS-C.

The Outcome of Cerumen Removal in the Pediatric Emergency Department

OBJECTIVE

Cerumen obstructs the visualization of the tympanic membrane (TM) in up to 40% of children, sometimes posing a challenge to rule out the diagnosis of acute otitis media (AOM) as the source of otalgia (for verbal children), irritability, fever, and febrile seizures. We aim to determine the rate at which removing the cerumen from blocking the view of the TM could change the management of these patients in the pediatric emergency department (PED).

METHODS

We retrospectively investigated all medical records of patients who underwent cerumen removal in the PED at a tertiary children's hospital from 2018 to 2019. We analyzed the effect of the procedure on the subsequent workup during their PED visit.

RESULTS

Of 482 children who presented to the PED with otalgia, irritability, fever, and/or febrile seizures and who were referred to an otolaryngologist for subsequent treatment after preliminary evaluation in the PED, 176 were included in the study group after having the cerumen removed from one or both ears. Seventy-three of them were given a diagnosis of AOM, 93 had a normal-appearing TM, and 10 had external otitis. Twenty-one percent of those with AOM and 46% of those with a normal TM ( P = 0.008) had blood drawn as part of their workup in their PED visit. The rate of chest x-rays was also significantly less for the AOM group (16% vs 30%, P = 0.03), and they also underwent fewer urine tests ( P = NS).

CONCLUSION

Cerumen removal changes the management of children in the PED who present with a possible diagnosis of an ear infection. Cerumen removal could avoid unnecessary laboratory and imaging studies, which could save time, costs, and suffering.

A Comparison Between Serum Selenium Level in Febrile Children with or Without Seizure

The role of trace elements in febrile seizure (FS) was considered recently. The present study was performed evaluating the serum level of selenium in febrile children aged 6-60 months with and without seizure. A cross-sectional study was performed in Mashhad University of Medical Sciences, Mashhad, Iran. Sixty patients aged 6-60 months including 30 children with FS and 30 febrile children without seizure were included. Blood sample was taken, and the serum level of selenium was measured. Data was analyzed using SPSS software. Sixteen patients in FS group (53.3%) and 10 patients in febrile group (33.3%) were males with an average age of 25.21 ± 15.91 and 26.47 ± 17.61 months, respectively. There was no significant difference between groups in age and sex (p = 0.77 and p = 0.19, respectively). The serum level of selenium was 87.34 ± 8.23 and 89.63 ± 9.83 µg/L in FS and febrile groups, respectively. Difference was not significant (p = 0.33). In children aged less than 1 year, the serum level of selenium in FS and febrile group was 83.32 ± 6.2 µg/L and 82.55 ± 8.32 µg/L, respectively. Difference was not significant (p = 0.87). In children aged more than 1 year, the serum level of selenium in FS significantly was lower compared to febrile group (87.96 ± 8.42 µg/L and 93.17 ± 8.66 µg/L, respectively, p = 0.04). The serum level of selenium was lower in children aged more than 1 year with febrile seizure compared to febrile ones.

ITPA-associated developmental and epileptic encephalopathy: characteristic neuroradiological features with novel clinical and biochemical findings

Developmental and epileptic encephalopathies (DEE) in children have an everexpanding range of rare causes. Mutations in ITPA have been recently described as causative of DEE, but only a small number of patients have been reported so far. We describe two Indian children with novel variants in the ITPA gene. Both patients had characteristic, previously described, neuroradiological findings that helped us suspect this condition even before genetic evaluation. In addition, we present new and rarely reported clinical findings associated with this condition: migrating partial epilepsy, fever-triggered seizures, movement disorder including oculogyria and dystonic tremor. One of the patients also had high cerebrospinal fluid glycine levels. Both patients had drug-responsive epilepsy, in contrast to drug-resistant seizures in previously reported patients. These patients reiterate the utility of awareness of specific neuroradiological findings and subsequent genetic evaluation to help make a precise diagnosis. Our report also extends the clinical spectrum and provides insight into possible biochemical causes for the neuroimaging findings seen in this condition.

Sense of control, selective attention and cognitive inhibition in pediatric functional seizures: A prospective case-control study

PURPOSE

To date, laboratory-based experimental behavioral methods have not been used to identify factors associated with pediatric functional seizures (FS), leaving a critical gap for effective treatment development.

METHODS

Children ages 13-18 with video-EEG-confirmed FS were matched to controls (MCs) based on income, sex, race, and age. A modified Stroop task which included a condition requiring participants to report the ink colors in which seizure symptom words were written (e.g., "shaking" in blue) measured selective attention and cognitive inhibition through response time. The magic and turbulence task assessed sense of control in three conditions (magic, lag, turbulence). Children with FS were asked to report premonitory symptoms predicting FS.

RESULTS

Participants included 26 children with FS and 26 MCs (Meanage=15.2, 74% female, 59% white). On Stroop, children with FS had a slower reaction time (Mean=1193.83) than MCs (Mean=949.26, p = 0.022) for seizure symptom words. Children with FS had significantly poorer sense of control in the turbulence condition of the magic and turbulence task (Mean=-3.99, SD=8.83) than MCs (Mean=-11.51, SD=7.87; t(20)=-2.61, p =0.017). Children with FS (Mean=-1.80, SD=6.54) also had significantly poorer sense of control in the magic condition than MCs (Mean=-5.57, SD=6.01; p =0.028). Ninety-eight percent of patients endorsed premonitory symptoms.

CONCLUSION

Compared with MCs, children with FS have (1) poorer selective attention and cognitive inhibition when presented with seizure-related information and (2) lower sense of control (i.e. poorer awareness that their control was manipulated). Premonitory symptoms were common. Sense of control, selective attention, and inhibition may be novel treatment targets for FS intervention.

GABRB3-related epilepsy: novel variants, clinical features and therapeutic implications

OBJECTIVE

This study aimed to comprehensively examine the genetic and phenotypic aspects of GABRB3-related epilepsy and to explore the potential prospects of personalized medicine.

METHODS

Genetic testing was conducted in all epilepsy patients without acquired factors for epilepsy. Through the collaboration of multicenter in China, we analyzed the genotype-phenotype correlation and antiepileptic therapy of 26 patients with GABRB3-related epilepsy.

RESULTS

Thirteen GABRB3 variants were novel, and 25 were de novo. The seizure onset age ranged from 1 to 21 months (median age 3.75 months). Seizure types predominated including focal seizures (92.3%), generalized tonic-clonic seizures (23.1%), and epileptic spasms (15.4%). Clinical features included cluster seizures (80.8%), fever sensitivity (53.8%), and developmental delay (96.2%). Neuroimaging was abnormal in 10 patients, including dysplasia of the cerebral cortex, dysplasia of the frontal and temporal cortex, delayed myelination, and corpus callosum dysplasia. Eleven patients were diagnosed with developmental and epileptic encephalopathy (DEE), four with West syndrome, three with epilepsy of infancy with migrating focal seizures (EIMFS), one with epilepsy with myoclonic-atonic seizures (EMAS), one with Dravet syndrome, and one with febrile seizures plus (FS+). Seizures were controlled in 57.7% of patients by valproate, levetiracetam, or perampanel in the majority.

CONCLUSIONS

The clinical features of GABRB3-related epilepsy included seizure onset in early infancy, cluster seizures and fever sensitivity. Most patients manifest severe epilepsy phenotypes. Valproate, levetiracetam and perampanel seem to have positive effects on seizure control for patients with GABRB3 variants.

Non-ocular risk factors in Turkish children with strabismus and amblyopia

BACKGROUND

To evaluate non-ocular risk factors including family history, febrile seizure, history of trauma, neurological diseases, and prematurity in Turkish children with strabismus and amblyopia.

METHODS

The records of patients diagnosed with strabismus and/or amblyopia below 18 years old, were recruited. The current mean age, sex, types and subtypes of strabismus and amblyopia, family history, history of trauma, and febrile seizure were investigated. The presence of neurological diseases and prematurity were noted. Family history was investigated whether the presence of strabismus or amblyopia was maternal or paternal. Blood relatives were divided into 3 groups including first, second, and third-degree relatives. The relationship between blood relative degrees and types of strabismus or amblyopia were assessed.

RESULTS

There were 803 patients with a current median age of 8 years (1-29 years). Of these patients, 786 patients could be evaluated and 55% had esotropia (ET), 32.6% had exotropia (XT) and 12.5% had amblyopia as a primary diagnosis. Positive family history of strabismus or amblyopia was more common among all risk factors. There was a statistically significant rate of patients with a positive family history in the first-degree relatives, in the esotropic patient group (p= 0.002). Maternal positive family history was more common in patients with refractive ET (p= 0.024) and paternal positive family history was more common in patients with intermittent XT (p= 0.009).

CONCLUSIONS

The rates of positive family history of amblyopia and strabismus were not statistically different. Family history of strabismus in first-degree relatives of patients with esotropia was markedly high. The family history of strabismus on the maternal or paternal side might be different in patients with different subtypes of strabismus.

[Dynamic change of hippocampal volume in children with recurrent febrile seizures]

OBJECTIVE

To study the change and significance of hippocampal volume (HCV) in children with recurrent febrile seizures.

METHODS

A retrospective analysis was performed on the medical data and examination results of 34 children with recurrent febrile seizures who underwent two magnetic resonance plain scans of the head and the hippocampus from January 1, 2013 to September 30, 2019. According to the follow-up time, they were divided into the first follow-up group and the second follow-up group. According to prognosis, they were divided into a febrile seizure group, a non-febrile group and an epilepsy group. The change in HCV was analyzed and compared.

RESULTS

Total HCV was positively correlated with age (rs=0.683, P < 0.05). The second follow-up group had a significantly larger total HCV than the first follow-up group (P < 0.05). For both groups, preschool children (≥ 3 years old) had significantly larger total HCV, left HCV, and right HCV than those at an age of < 3 years (P < 0.05). For both groups, the children with persistent seizures had significantly lower average annual increment (ΔV) of total HCV, left HCV, and right HCV than those without persistent seizures (P < 0.05). There was no significant difference in ΔV of total HCV, left HCV, and right HCV among the febrile seizure, non-febrile seizure and epilepsy groups (P > 0.05).

CONCLUSIONS

HCV gradually increases with age in children with recurrent febrile seizures. Persistent seizures may damage the development of the hippocampus.

[Dynamic change of hippocampal volume in children with recurrent febrile seizures]

OBJECTIVE

To study the change and significance of hippocampal volume (HCV) in children with recurrent febrile seizures.

METHODS

A retrospective analysis was performed on the medical data and examination results of 34 children with recurrent febrile seizures who underwent two magnetic resonance plain scans of the head and the hippocampus from January 1, 2013 to September 30, 2019. According to the follow-up time, they were divided into the first follow-up group and the second follow-up group. According to prognosis, they were divided into a febrile seizure group, a non-febrile group and an epilepsy group. The change in HCV was analyzed and compared.

RESULTS

Total HCV was positively correlated with age (r_s=0.683, P < 0.05). The second follow-up group had a significantly larger total HCV than the first follow-up group (P < 0.05). For both groups, preschool children (≥ 3 years old) had significantly larger total HCV, left HCV, and right HCV than those at an age of < 3 years (P < 0.05). For both groups, the children with persistent seizures had significantly lower average annual increment (ΔV) of total HCV, left HCV, and right HCV than those without persistent seizures (P < 0.05). There was no significant difference in ΔV of total HCV, left HCV, and right HCV among the febrile seizure, non-febrile seizure and epilepsy groups (P > 0.05).

CONCLUSIONS

HCV gradually increases with age in children with recurrent febrile seizures. Persistent seizures may damage the development of the hippocampus.

Clinical profile and treatment outcome of epilepsy syndromes in children: A hospital-based study in Eastern Nepal

Objective

It is often difficult to diagnose epilepsy syndromes in resource-limited settings. This study was aimed to investigate the prospect of ascertaining the diagnosis, clinical profile, and treatment outcomes of epilepsy syndromes (ESs) among children in a resource-limited setting.

Methods

This was a descriptive study done from 01/07/2009 to 15/06/2017 among children (1-17 years of age) with unprovoked seizures presenting to the pediatric neurology clinic of a university hospital in eastern Nepal. Diagnosis, classification, and treatment of seizures were based upon International League Against Epilepsy guidelines.

Results

Of 768 children with unprovoked seizures, 120 (15.6%) were diagnosed as ES. The age of onset of seizure was unique for each ES. Developmental delay and cerebral palsy were present in 47.5% and 28.3% children, respectively. Common ESs were West syndrome (WS)-26.7%, generalized tonic-clonic seizures alone (GTCSA)-21.7%, self-limited childhood epilepsy with centrotemporal spikes (SLCECTS)-12.5%, childhood absence epilepsy (CAE)-10.0%, Lennox-Gastaut syndrome (LGS)-10.0%, other developmental and epileptic encephalopathies (DEE)-5.8%, self-limited familial infantile epilepsy (SLFIE)-4.2%, and juvenile myoclonic epilepsy (JME)-3.3%. Among children with known outcomes (87/120), overall response to pharmacotherapy and to monotherapy was observed in 72.4% (63/87) and 57.5% (50/87) children, respectively. All children with GTCSA, SLFIE, genetic epilepsy with febrile seizure plus (GEFS+), CAE, SLCECTS, and JME responded to pharmacotherapy and they had normal computerized tomography scans of the brain. Seizures were largely pharmaco-resistant in progressive myoclonus epilepsy (PME)-100.0%, LGS-73.0%, WS-52.0%, and other DEEs-40%.

Significance

A reasonable proportion (15.6%) of unprovoked seizures could be classified into specific ES despite limited diagnostic resources. WS was the most common ES. GTCSA, SLCECTS, CAE, and LGS were other common ESs. GTCSA, SLFIE, CAE, SLCECTS, GEFS+, and JME were largely pharmaco-responsive. PME, WS, and LGS were relatively pharmaco-resistant. Electro-clinical diagnosis of certain ES avoids the necessity of neuroimaging.

Length of stay linked to neurodiagnostic workup for seizures presenting to the pediatric emergency department

INTRODUCTION

Patients presenting to the pediatric emergency department (ED) often undergo unnecessary testing that leads to prolonged ED visits. Lower ED length of stay has been linked to improved patient experience and may reduce ED overcrowding, a costly burden on a health system.

METHODS

This is a retrospective cohort study involving patient records over the period of 6 months at an urban tertiary children's hospital who presented with seizures. Febrile seizures, seizures associated with trauma, and charts of patients who did not present initially through our ED were excluded.

RESULTS

328 charts were obtained through this search criteria. Head imaging was performed in 52 (16%) patients and consisted of 81% CT (n = 42) and 19% (n = 10) magnetic resonance imaging (MRI). Obtaining an MRI was associated with a 3.5 h longer ED visit (p = 0.07); obtaining a CT was associated with a 1.5 h longer ED visit (p = 0.005). An Electroencephalogram (EEG) was obtained for 67 (20%) visits and was associated with a 3.0 h longer ED length of stay (p < 0.001). Ten % of the CT scans showed new or progressive findings and 40% of the MRIs done provided useful information for management. Thirty-seven % of EEGs performed in new onset seizure patients revealed epileptiform findings and 5% of EEGs in established seizure patients provided meaningful findings important to management.

CONCLUSION

Obtaining neurodiagnostic studies significantly prolongs duration of stay in the ED. Electroencephalograms appear to have the greatest yield in new onset seizure patients and can help make a diagnosis of an epilepsy syndrome in children.

Glutamatergic System is Affected in Brain from an Hyperthermia-Induced Seizures Rat Model

One of the most frequent neurological disorders in children is febrile seizures (FS), a risk for epilepsy in adults. Glutamate is the main excitatory neurotransmitter in CNS acting through ionotropic and metabotropic receptors. Excess of glutamate in the extracellular space elicits excitotoxicity and has been associated with neurological disorders, such as epilepsy. The removal of extracellular glutamate by excitatory amino acid transporters (EATT) plays an important neuroprotective role. GLT-1 is the main EAAT present in the cortex brain. On the other hand, an increase in metabotropic glutamate receptors 5 (mGlu₅R) levels or their overstimulation have been related to the appearance of seizure events in different animal models and in temporal lobe epilepsy in humans. In this work, the status of several components of the glutamatergic system has been analysed in the cortex brain from an FS rat model at short (48 h) and long (20 days) term after hyperthermia-induced seizures. At the short term, we detected increased GLT-1 levels, reduced glutamate concentration, and unchanged mGlu₅R levels, without neuronal loss. However, at the long term, an increase in mGlu₅R levels together with a decrease in both GLT-1 and glutamate levels were observed. These changes were associated with the appearance of an anxious phenotype. These results suggest a neuroprotective role of the glutamatergic components mGlu₅R and GLT-1 at the short term. However, this neuroprotective effect seems to be lost at the long term, leading to an anxious phenotype and suggesting an increased vulnerability and propensity to epileptic events in adults.

[Magnetic resonance imaging morphological study of the effects of juvenile febrile convulsions on the brain structure of medial temporal lobe epilepsy]

Objective: To investigate the effect of febrile convulsions on gray matter volume (GMV) in medial temporal lobe epilepsy (mTLE) and its correlation with disease duration. Methods: A retrospective study was conducted to collect 41 mTLE patients with a history of febrile convulsions (mTLE-FC), 42 mTLE patients with no initial precipitating injury (mTLE-noIPI), and 42 normal and age and sex matched normal controls. High-resolution T1-weighted (T(1)WI) whole brain MR scans were performed on all subjects. Voxel-based morphometry were used to obtain GMV brain maps, and the GMV differences between the three groups of subjects were compared (P<0.01, GRF corrected). Finally, Spearmen rank correlation analysis was used to explore the correlation between GMV changes and the course of disease. Results: Compared with the normal control subjects, each mTLE group showed extensive GMV reduction, mainly in the affected hippocampus, thalamus, temporal lobe, and bilateral cerebellum. Further analysis found that mTLE-FC group had more significant reductions in GMV than the mTLE-noIPI group in the affected hippocampus, amygdala, inferior temporal gyrus, contralateral hippocampus, para hippocampus, and inner cingulate gyrus. At the same time, the affected amygdala and hippocampal GMV in the mTLE-FC group was significantly negatively related to the course of disease (r=-0.381, P=0.014), while the mTLE-noIPI group had no downward trend (r=0.081, P=0.611). The atrophic trend of the affected amygdala and hippocampus in patients with mTLE-FC was significantly greater than that in patients with mTLE-noIPI (P=0.029, permutation test). Conclusions: There is extensive damage to the gray matter structure of bilateral cerebral hemispheres, mainly in the hippocampus, in mTLE patients. The brain damage of mTLE patients with a history of juvenile fever convulsions is more extensive and serious, and the trend of progressive exacerbation with the course of the disease is more obvious, suggesting mTLE associated with juvenile fever convulsions may have different pathophysiological mechanisms.

EEG for children with complex febrile seizures

BACKGROUND

Febrile seizures can be classified as simple or complex. Complex febrile seizures are associated with fever that lasts longer than 15 minutes, occur more than once within 24 hours, and are confined to one side of the child's body. It is common in some countries for doctors to recommend an electroencephalograph (EEG) for children with complex febrile seizures. A limited evidence base is available to support the use of EEG and its timing after complex febrile seizures among children.

OBJECTIVES

To assess the use of EEG and its timing after complex febrile seizures in children younger than five years of age.

SEARCH METHODS

For the latest update of this review, we searched the following databases on 12 March 2019: Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (Ovid, 1946 to 11 March 2019); and ClinicalTrials.gov. We applied no language restrictions.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that examined the utility of an EEG and its timing after complex febrile seizures in children.

DATA COLLECTION AND ANALYSIS

The review authors selected and retrieved the articles and independently assessed which articles should be included. Any disagreements were resolved by discussion and by consultation with the Cochrane Epilepsy Group. We applied standard methodological procedures expected by Cochrane.

MAIN RESULTS

Of 48 potentially eligible studies, no RCTs met the inclusion criteria.

AUTHORS' CONCLUSIONS

We found no RCTs as evidence to support or refute the use of EEG and its timing after complex febrile seizures among children under the age of five. An RCT can be planned in such a way that participants are randomly assigned to the EEG group and to the non-EEG group with sufficient sample size. Since the last version of this review, we have found no new studies.

Long-term outcomes after childhood convulsive status epilepticus

PURPOSE OF REVIEW

It is widely accepted that childhood convulsive status epilepticus (CSE) has associated short-term and long-term mortality and morbidity. However, the role of CSE itself on subsequent adverse outcomes is still debated. In addition, whether prolonged seizures cause any long-term hippocampal injury and developmental or memory impairment is uncertain. In this review, we aim to provide an overview of long-term outcomes after childhood CSE, highlighting data from recent literature on this subject.

RECENT FINDINGS

Long-term outcome after childhood CSE is favorable in previously normal children, with low incidence of epilepsy, motor and intellectual disability, behavioral impairment and need for special educational provision. Mesial temporal sclerosis is uncommon in children after prolonged febrile seizures. There is substantial morbidity after childhood CSE, but this is seen primarily in children with symptomatic causes and preexisting neurological abnormalities. Cause is the primary determinant of outcomes after childhood CSE and the additional effect of CSE characteristics such as seizure duration seems to be less than previously believed.

SUMMARY

Childhood CSE is associated with substantial neurological, cognitive and behavioral morbidity. Early identification of these difficulties and appropriate intervention are likely to have a major positive impact on their quality of life.

Anthropogenetic Variability in the Group of Individuals with Febrile Seizures: Population-Genetic Study

Febrile seizures (FS) are the most common neurological disorder in childhood and are a great stress for parents due to their dramatic clinical appearance. Using test for determination of homozygously recessive characteristics in humans (HRC test) we analyzed presence, distribution, and individual combination of 20 selected genetically controlled morphophysiological traits among FS patients (N=121) and control (N=121) to determine a possible deviation in the homozygosity level and genetic loads in the group of affected children and whether there is a predisposition to the occurrence of FS. The results of our study show a statistically significant difference in the mean values of the HRC tested ( x ¯ H R C / 20 CN = 3.2 ± 0.2; x ¯ H R C / 20 FS = 4.6 ± 0.2, t= 5.74 , p< 0.0001), as well as in the distribution and variability of two studied samples (VC=55,3%, VFS= 39,6%), which indicates a complex polygenic difference among the tested groups of subjects. The differences in the degree of genetic homozygosity and variability are also present between the genders (t Cf/FSf = 4.12; t Cm/FSm = 3.98; p <0.0001) (VCf=56.9%, VFSf= 39.3%; VCm=54.1%, VFSm=40.1%). Obtained results indicate the enlargement of recessively homozygous genetic loads in the group of children with FS which may represent some kind of predisposition for expressivity of this type of seizures.

An objective score to identify psychogenic seizures based on age of onset and history

OBJECTIVE

Psychogenic nonepileptic seizure (PNES) is a common diagnosis after evaluation of medication resistant or atypical seizures with video-electroencephalographic monitoring (VEM), but usually follows a long delay after the development of seizures, during which patients are treated for epilepsy. Therefore, more readily available diagnostic tools are needed for earlier identification of patients at risk for PNES. A tool based on patient-reported psychosocial history would be especially beneficial because it could be implemented in the outpatient clinic.

METHODS

Based on the data from 1375 patients with VEM-confirmed diagnoses, we used logistic regression to compare the frequency of specific patient-reported historical events, demographic information, age of onset, and delay from first seizure until VEM in five mutually exclusive groups of patients: epileptic seizures (ES), PNES, physiologic nonepileptic seizure-like events (PSLE), mixed PNES plus ES, and inconclusive monitoring. To determine the diagnostic utility of this information to differentiate PNES only from ES only, we used multivariate piecewise-linear logistic regression trained using retrospective data from chart review and validated based on data from 246 prospective standardized interviews.

RESULTS

The prospective area under the curve of our weighted multivariate piecewise-linear by-sex score was 73%, with the threshold that maximized overall retrospective accuracy resulting in a prospective sensitivity of 74% (95% CI: 70-79%) and prospective specificity of 71% (95% CI: 64-82%). The linear model and piecewise linear without an interaction term for sex had very similar performance statistics. In the multivariate piecewise-linear sex-split predictive model, the significant factors positively associated with ES were history of febrile seizures, current employment or active student status, history of traumatic brain injury (TBI), and longer delay from first seizure until VEM. The significant factors associated with PNES were female sex, older age of onset, mild TBI, and significant stressful events with sexual abuse, in particular, increasing the likelihood of PNES. Delays longer than 20years, age of onset after 31years for men, and age of onset after 40years for women had no additional effect on the likelihood of PNES.

DISCUSSION

Our promising results suggest that an objective score has the potential to serve as an early outpatient screening tool to identify patients with greater likelihood of PNES when considered in combination with other factors. In addition, our analysis suggests that sexual abuse, more than other psychological stressors including physical abuse, is more associated with PNES. There was a trend of increasing frequency of PNES for women during childbearing years and plateauing outside those years that was not observed in men.

EEG for children with complex febrile seizures

BACKGROUND

Febrile seizures can be classified as simple or complex. Complex febrile seizures are associated with fever that lasts longer than 15 minutes, occur more than once within 24 hours, and are confined to one side of the child's body. It is common in some countries for doctors to recommend an electroencephalograph (EEG) for children with complex febrile seizures. A limited evidence base is available to support the use of EEG and its timing after complex febrile seizures among children.

OBJECTIVES

To assess the use of EEG and its timing after complex febrile seizures in children younger than five years of age.

SEARCH METHODS

For the latest update of this review, we searched the Cochrane Epilepsy Group Specialized Register (23 January 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO, 23 January 2017), MEDLINE (Ovid, 23 January 2017), and ClinicalTrials.gov (23 January 2017). We applied no language restrictions.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that examined the utility of an EEG and its timing after complex febrile seizures in children.

DATA COLLECTION AND ANALYSIS

The review authors selected and retrieved the articles and independently assessed which articles should be included. Any disagreements were resolved by discussion and by consultation with the Cochrane Epilepsy Group. We applied standard methodological procedures expected by Cochrane.

MAIN RESULTS

Of 41 potentially eligible studies, no RCTs met the inclusion criteria.

AUTHORS' CONCLUSIONS

We found no RCTs as evidence to support or refute the use of EEG and its timing after complex febrile seizures among children. An RCT can be planned in such a way that participants are randomly assigned to the EEG group and to the non-EEG group with sufficient sample size. Since the last version of this review, we have found no new studies.

[The Role of Blood-Brain Barrier in the Development of Childhood Febrile Seizures and Temporal Lobe Epilepsy.]

Blood-brain barrier (BBB) of the central nervous system (CNS) is a physiological barrier that makes it possible to control the exchange of ions, molecules and cells between blood and tissue and to prevent their free inflow into the brain. BBB is crucial for maintenance of brain homeostasis. BBB damage accompanies many degenerative, neurological and inflammatory (infectious or noninfectious) diseases and pathological states. Current review reports about BBB role in development of childhood febrile seizures and temporal lobe epi- lepsy.

[Genotype and phenotype of female Dravet syndrome with PCDH19 mutations]

OBJECTIVE

To explore the genotype and phenotype of female Dravet syndrome (DS) patients with PCDH19 mutations.

METHOD

Clinical data of all DS patients seen at Pediatric Department of Peking University First Hospital from February 2005 to May 2015 were prospectively collected. Genomic DNAs were extracted from the patients and their family members. Female DS patients without SCN1A mutation were enrolled. PCR and Sanger sequencing were performed to identify PCDH19 mutations. Clinical data of DS patients with PCDH19 mutations were summarized.

RESULT

Five different heterozygous PCDH19 mutations were identified in six unrelated patients of 75 SCN1A-negative female DS patients (8%), among whom five patients had de novo mutations and one patient's mutation was inherited from her affected mother. Three missense mutations and two insertion mutations were all located in exon 1. Mean age of onset of the six patients with PCDH19 mutations was 6.8 months (range 5-9 months). Onset of seizures were triggered by fever in four patients, after vaccination in one and without fever in one. Generalized tonic clonic seizure (GTCS) was the first seizure type in four patients and focal seizure with secondary generalized tonic clonic seizures in the remaining two. During the course, all patients presented multiple seizure types including generalized tonic clonic seizures and focal seizures in all six patients, myoclonic seizures in three, absence seizures and atonic seizures in one respectively. In all patients, seizures manifested fever-sensitive and in clusters. Seizures were always in brief duration, in most less than 5 minutes, except one experienced twice status epilepticus triggered by fever. Six patients had development delay after the seizure onset, two with autism spectrum disorder, three with ataxia.

CONCLUSION

PCDH19 is another important gene of DS after SCN1A, mutations mainly occurred de novo. PCDH19 gene mutation should be routinely screened in female DS patients without SCN1A mutation. The clinical features of female DS patients with PCDH19 mutations include that the main seizures types are generalized tonic clonic seizures and focal seizures, seizures occurr in clusters and fever-sensitive, short seizure duration, rare status epilepticus, common development delay and some may manifest autism spectrum disorders.

EEG for children with complex febrile seizures

BACKGROUND

This is an updated version of original Cochrane review published in Issue 1, 2014.Febrile seizures can be classified as simple or complex. Complex febrile seizures are associated with fever that lasts longer than 15 minutes, occur more than once within 24 hours and are confined to one side of the child's body. It is common in some countries for doctors to recommend an electroencephalograph (EEG) for children with complex febrile seizures. A limited evidence base is available to support the use of EEG and its timing after complex febrile seizures among children.

OBJECTIVES

To assess the use of EEG and its timing after complex febrile seizures in children younger than five years of age.

SEARCH METHODS

For the latest update of this review, we searched the Cochrane Epilepsy Group Specialized Register (6 July 2015), the Cochrane Central Register of Controlled Trials (CENTRAL, 2005, Issue 6), MEDLINE (6 July 2015) and ClinicalTrials.gov (6 July 2015). We applied no language restrictions.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that examined the utility of an EEG and its timing after complex febrile seizures in children.

DATA COLLECTION AND ANALYSIS

Review authors selected and retrieved the articles and independently assessed which articles should be included. We resolved disagreements by discussion and by consultation with the Cochrane Epilepsy Group. We applied standard methodological procedures expected by Cochrane.

MAIN RESULTS

Of 37 potentially eligible studies, no RCTs met the inclusion criteria.

AUTHORS' CONCLUSIONS

We found no RCTs as evidence to support or refute the use of EEG and its timing after complex febrile seizures among children. An RCT can be planned in such a way that participants are randomly assigned to the EEG group and to the non-EEG group with sufficient sample size. Since the last version of this review, we found no new studies.

[Phenotypes and PRRT2 mutation analysis in families with benign familial infantile epilepsy]

OBJECTIVE

To study the phenotypes and proline-rich transmembrane protein 2 (PRRT2) mutations in families with benign familial infantile epilepsy (BFIE).

METHOD

Data of all BFIE probands and their family members were collected from Peking University First Hospital between September 2006 and August 2013. Clinical phenotypes of affected members were analyzed. Genomic DNA was extracted from peripheral blood samples with standard protocol. Mutations in PRRT2 were screened using PCR amplification and Sanger sequencing.

RESULT

Twenty-nine BFIE families were recruited in this study. In total, 110 family members were affected. The age of seizure onset of these affected members was between 2 and 12 months (median: 4.5 months). All probands presented with clusters of seizures. Two probands had one seizure induced by diarrhea respectively at 25 months and 31 months. In four BFIE families, four family members had a history of febrile seizures. PRRT2 mutations were found in 17 of the 29 (58.6%) BFIE families. Mutation c.649_650insC was detected in 12 of the 17 families with PRRT2 mutations. Mutation c.649delC (p.R217EfsX12) was identified in three families. Mutation c.323_324delCA (p. T108SfsX25) and c.904_ 905insG (p. D302GfsX39) were detected in one family, respectively.

CONCLUSION

The minimum seizure onset age of affected members in BFIE families was 2 months of age. The seizures often occur in clusters. PRRT2 is the major causative gene of BFIE in Chinese families. Mutation c.649_650insC is the hotspot mutation of PRRT2. A novel mutation c.323_324delCA was first reported in BFIE family. Few affected members with PRRT2 mutation presented with febrile seizures phenotype.

EEG for children with complex febrile seizures

BACKGROUND

Febrile seizures can be classified as simple or complex. Complex febrile seizures are associated with fever that lasts longer than 15 minutes, occur more than once within 24 hours and are confined to one side of the child's body. It is common in some countries for doctors to recommend an electroencephalograph (EEG) for children with complex febrile seizures. A limited evidence base is available to support the use of EEG and its timing after complex febrile seizures among children.

OBJECTIVES

To assess the use of EEG and its timing after complex febrile seizures in children younger than five years of age.

SEARCH METHODS

We searched the Cochrane Epilepsy Group Specialised Register (17 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9, 2013), MEDLINE (17 October 2013) and the Clinical Trial Registry (ClinicalTrials.gov (17 October 2013)). We applied no language restrictions.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that examined the utility of an EEG and its timing after complex febrile seizures in children.

DATA COLLECTION AND ANALYSIS

Review authors selected and retrieved the articles and independently assessed which articles should be included. Disagreements were resolved by discussion and by consultation with the Cochrane Epilepsy Group. We applied standard methodological procedures expected by The Cochrane Colloboration.

MAIN RESULTS

Of 33 potentially eligible studies, no RCTs met the inclusion criteria.

AUTHORS' CONCLUSIONS

We found no RCTs as evidence to support or refute the use of EEG and its timing after complex febrile seizures among children. A randomised controlled trial can be planned in such a way that participants are randomly assigned to the EEG group and to the non-EEG group with sufficient sample size.

Matrix metalloproteinase-9 and tissue inhibitors of metalloproteinases 1 in influenza-associated encephalopathy

Matrix metalloproteinase-9 (MMP-9) and tissue inhibitors of metalloproteinases 1 (TIMP-1) play important roles in the function of the blood-brain barrier. Serum MMP-9 and TIMP-1 concentrations were determined in influenza virus infection with or without neurologic complications. Our results suggest that an imbalance between MMP-9 and TIMP-1 damages the blood-brain barrier and promotes febrile seizure or encephalopathy in influenza virus infection.