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Knight P, Norman V, Gully R, Wood D, Raffaj D, Riddick L, Hancock S, Revanna S, Uvaise M, Herring S, Worrall M, Daye A, Terris M, O'Brien C, Kumar A, Scott S, Pritchard L, Palaniappan S, Hughes C, Griksaitis MJ, Riphagen S, Ramnarayan P. Can critical care transport be safely reduced in children intubated during emergency management of status epilepticus in the United Kingdom: a national audit with case-control analysis. Arch Dis Child 2024; 109:476-481. [PMID: 38448198 DOI: 10.1136/archdischild-2023-326320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/02/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE This study describes the baseline clinical characteristics, predictors of successful extubation at referring hospitals and short-term outcomes of children intubated for status epilepticus and referred to United Kingdom (UK) paediatric critical care transport teams (PCCTs). DESIGN Multicentre audit with case-control analysis, conducted between 1 September 2018 and 1 September 2020. SETTING This study involved 10 UK PCCTs. PATIENTS Children over 1 month of age intubated during emergency management for status epilepticus (SE), referred to UK PCCTs. Patients with trauma, requiring time-critical neurosurgical intervention or those with a tracheostomy were excluded. INTERVENTIONS No interventions were implemented. MEASUREMENTS AND MAIN RESULTS Out of the 1622 referrals for SE, 1136 (70%) were intubated at referral. The median age was 3 years (IQR 1.25-6.54 years). Among the intubated children, 396 (34.8%) were extubated locally by the referring team, with 19 (4.8%) requiring reintubation. Therefore, the overall rate of successful extubation was 33% (377/1136). There was significant variation between PCCTs, with local extubation rates ranging from 2% to 74%. Multivariable analyses showed region/PCCT, contributing diagnosis, acute changes on CT, preceding encephalopathy and type of continuous sedation (midazolam) used postintubation were significantly associated with transfer to a critical care unit. CONCLUSION This study highlights wide regional variation in early extubation practices. Regions with high successful extubation rates have established extubation guidelines from PCCTs. Successful extubation represents critical care transports that have been avoided.
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Affiliation(s)
- Philip Knight
- Paediatric Intensive Care, King's College London, London, UK
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Victoria Norman
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Rochelle Gully
- Wales and West Acute Transport for Children Service (WATCh), Bristol Royal Hospital for Children, Bristol, UK
| | - Dora Wood
- Wales and West Acute Transport for Children Service (WATCh), Bristol Royal Hospital for Children, Bristol, UK
| | - Dusan Raffaj
- Children's Medical Emergency Transport (COMET), Leicester Royal Infirmary Children's Services, Leicester, UK
| | - Laura Riddick
- Embrace Yorkshire & Humber Infant & Children's Transport Service (Embrace), Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Stephen Hancock
- Embrace Yorkshire & Humber Infant & Children's Transport Service (Embrace), Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Sanjay Revanna
- Kids Intensive Care and Decision Support and Neonatal Transports Service (KIDSNTS), Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Mohammed Uvaise
- South Thames Retrieval Service at Evelina London Children's Hospital, Evelina London Children's Healthcare, London, UK
| | - Sasha Herring
- South Thames Retrieval Service at Evelina London Children's Hospital, Evelina London Children's Healthcare, London, UK
| | - Mark Worrall
- Paediatric Critical Care Transport-ScotSTAR, Royal Hospital for Children, Glasgow, UK
| | - Ashley Daye
- Paediatric Critical Care Transport-ScotSTAR, Royal Hospital for Children, Glasgow, UK
| | - Mark Terris
- Northern Ireland Specialist Transport and Retrieval (NISTAR), Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Cormac O'Brien
- Northern Ireland Specialist Transport and Retrieval (NISTAR), Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Ananth Kumar
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Sophie Scott
- Wales and West Acute Transport for Children Service (WATCh), Bristol Royal Hospital for Children, Bristol, UK
| | - Lisa Pritchard
- Northwest & North Wales Paediatric Transport Service (NWTS), Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Srinivasan Palaniappan
- Northwest & North Wales Paediatric Transport Service (NWTS), Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Charlotte Hughes
- Southampton Oxford Retrieval Team (SORT), Southampton Children's Hospital, Southampton, UK
| | - Michael J Griksaitis
- Paediatric Intensive Care Unit, Southampton Oxford Retrieval Team (SORT), Southampton Children's Hospital, Southampton, UK
| | - Shelley Riphagen
- South Thames Retrieval Service at Evelina London Children's Hospital, Evelina London Children's Healthcare, London, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Oh A, Wusthoff CJ, Kim H. Continuous Electroencephalogram Use and Hospital Outcomes in Critically Ill Children. J Clin Neurophysiol 2024; 41:291-296. [PMID: 36893384 DOI: 10.1097/wnp.0000000000000993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 12/13/2022] [Indexed: 03/11/2023] Open
Abstract
PURPOSE To examine the association between CEEG use and discharge status, length of hospitalization, and health care cost in a critically ill pediatric population. METHODS Four thousand three hundred forty-eight critically ill children were identified from a US nationwide administrative health claims database; 212 (4.9%) of whom underwent CEEG during admissions (January 1, 2015-june 30, 2020). Discharge status, length of hospitalization, and health care cost were compared between patients with and without CEEG use. Multiple logistic regression analyzed the association between CEEG use and these outcomes, controlling for age and underlying neurologic diagnosis. Prespecified subgroups analysis was performed for children with seizures/status epilepticus, with altered mental status and with cardiac arrest. RESULTS Compared with critically ill children without CEEG, those who underwent CEEG were likely to have shorter hospital stays than the median (OR = 0.66; 95% CI = 0.49-0.88; P = 0.004), and also total hospitalization costs were less likely to exceed the median (OR = 0.59; 95% CI = 0.45-0.79; P < 0.001). There was no difference in odds of favorable discharge status between those with and without CEEG (OR = 0.69; 95% CI = 0.41-1.08; P = 0.125). In the subgroup of children with seizures/status epilepticus, those with CEEG were less likely to have unfavorable discharge status, compared with those without CEEG (OR = 0.51; 95% CI = 0.27-0.89; P = 0.026). CONCLUSIONS Among critically ill children, CEEG was associated with shorter stay and lower costs of hospitalization but was not associated with change of favorable discharge status except the subgroup with seizures/status epilepticus.
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Affiliation(s)
- Ahyuda Oh
- Departments of Neurology and Neurological Sciences; and
| | - Courtney J Wusthoff
- Departments of Neurology and Neurological Sciences; and
- Pediatrics, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Hyunmi Kim
- Departments of Neurology and Neurological Sciences; and
- Pediatrics, Stanford University School of Medicine, Palo Alto, California, U.S.A
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Coleman K, Fung FW, Topjian A, Abend NS, Xiao R. Optimizing EEG monitoring in critically ill children at risk for electroencephalographic seizures. Seizure 2024; 117:244-252. [PMID: 38522169 DOI: 10.1016/j.seizure.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/06/2024] [Accepted: 03/19/2024] [Indexed: 03/26/2024] Open
Abstract
OBJECTIVE Strategies are needed to optimally deploy continuous EEG monitoring (CEEG) for electroencephalographic seizure (ES) identification and management due to resource limitations. We aimed to construct an efficient multi-stage prediction model guiding CEEG utilization to identify ES in critically ill children using clinical and EEG covariates. METHODS The largest prospective single-center cohort of 1399 consecutive children undergoing CEEG was analyzed. A four-stage model was developed and trained to predict whether a subject required additional CEEG at the conclusion of each stage given their risk of ES. Logistic regression, elastic net, random forest, and CatBoost served as candidate methods for each stage and were evaluated using cross validation. An optimal multi-stage model consisting of the top-performing stage-specific models was constructed. RESULTS When evaluated on a test set, the optimal multi-stage model achieved a cumulative specificity of 0.197 and cumulative F1 score of 0.326 while maintaining a high minimum cumulative sensitivity of 0.938. Overall, 11 % of test subjects with ES were removed from the model due to a predicted low risk of ES (falsely negative subjects). CEEG utilization would be reduced by 32 % and 47 % compared to performing 24 and 48 h of CEEG in all test subjects, respectively. We developed a web application called EEGLE (EEG Length Estimator) that enables straightforward implementation of the model. CONCLUSIONS Application of the optimal multi-stage ES prediction model could either reduce CEEG utilization for patients at lower risk of ES or promote CEEG resource reallocation to patients at higher risk for ES.
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Affiliation(s)
- Kyle Coleman
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, United States
| | - France W Fung
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, United States; Department of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, United States
| | - Alexis Topjian
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, United States
| | - Nicholas S Abend
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, United States; Department of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, United States; Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, United States; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, United States
| | - Rui Xiao
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, United States; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, United States.
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4
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Jing J, Ge W, Struck AF, Fernandes MB, Hong S, An S, Fatima S, Herlopian A, Karakis I, Halford JJ, Ng MC, Johnson EL, Appavu BL, Sarkis RA, Osman G, Kaplan PW, Dhakar MB, Jayagopal LA, Sheikh Z, Taraschenko O, Schmitt S, Haider HA, Kim JA, Swisher CB, Gaspard N, Cervenka MC, Rodriguez Ruiz AA, Lee JW, Tabaeizadeh M, Gilmore EJ, Nordstrom K, Yoo JY, Holmes MG, Herman ST, Williams JA, Pathmanathan J, Nascimento FA, Fan Z, Nasiri S, Shafi MM, Cash SS, Hoch DB, Cole AJ, Rosenthal ES, Zafar SF, Sun J, Westover MB. Interrater Reliability of Expert Electroencephalographers Identifying Seizures and Rhythmic and Periodic Patterns in EEGs. Neurology 2023; 100:e1737-e1749. [PMID: 36460472 PMCID: PMC10136018 DOI: 10.1212/wnl.0000000000201670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 10/25/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The validity of brain monitoring using electroencephalography (EEG), particularly to guide care in patients with acute or critical illness, requires that experts can reliably identify seizures and other potentially harmful rhythmic and periodic brain activity, collectively referred to as "ictal-interictal-injury continuum" (IIIC). Previous interrater reliability (IRR) studies are limited by small samples and selection bias. This study was conducted to assess the reliability of experts in identifying IIIC. METHODS This prospective analysis included 30 experts with subspecialty clinical neurophysiology training from 18 institutions. Experts independently scored varying numbers of ten-second EEG segments as "seizure (SZ)," "lateralized periodic discharges (LPDs)," "generalized periodic discharges (GPDs)," "lateralized rhythmic delta activity (LRDA)," "generalized rhythmic delta activity (GRDA)," or "other." EEGs were performed for clinical indications at Massachusetts General Hospital between 2006 and 2020. Primary outcome measures were pairwise IRR (average percent agreement [PA] between pairs of experts) and majority IRR (average PA with group consensus) for each class and beyond chance agreement (κ). Secondary outcomes were calibration of expert scoring to group consensus, and latent trait analysis to investigate contributions of bias and noise to scoring variability. RESULTS Among 2,711 EEGs, 49% were from women, and the median (IQR) age was 55 (41) years. In total, experts scored 50,697 EEG segments; the median [range] number scored by each expert was 6,287.5 [1,002, 45,267]. Overall pairwise IRR was moderate (PA 52%, κ 42%), and majority IRR was substantial (PA 65%, κ 61%). Noise-bias analysis demonstrated that a single underlying receiver operating curve can account for most variation in experts' false-positive vs true-positive characteristics (median [range] of variance explained ([Formula: see text]): 95 [93, 98]%) and for most variation in experts' precision vs sensitivity characteristics ([Formula: see text]: 75 [59, 89]%). Thus, variation between experts is mostly attributable not to differences in expertise but rather to variation in decision thresholds. DISCUSSION Our results provide precise estimates of expert reliability from a large and diverse sample and a parsimonious theory to explain the origin of disagreements between experts. The results also establish a standard for how well an automated IIIC classifier must perform to match experts. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that an independent expert review reliably identifies ictal-interictal injury continuum patterns on EEG compared with expert consensus.
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Affiliation(s)
- Jin Jing
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Wendong Ge
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Aaron F Struck
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Marta Bento Fernandes
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Shenda Hong
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sungtae An
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Safoora Fatima
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Aline Herlopian
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Ioannis Karakis
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jonathan J Halford
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Marcus C Ng
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Emily L Johnson
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Brian L Appavu
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Rani A Sarkis
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Gamaleldin Osman
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Peter W Kaplan
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Monica B Dhakar
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Lakshman Arcot Jayagopal
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Zubeda Sheikh
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Olga Taraschenko
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sarah Schmitt
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Hiba A Haider
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jennifer A Kim
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Christa B Swisher
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Nicolas Gaspard
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Mackenzie C Cervenka
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Andres A Rodriguez Ruiz
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jong Woo Lee
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Mohammad Tabaeizadeh
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Emily J Gilmore
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Kristy Nordstrom
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Ji Yeoun Yoo
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Manisha G Holmes
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Susan T Herman
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jennifer A Williams
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jay Pathmanathan
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Fábio A Nascimento
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Ziwei Fan
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Samaneh Nasiri
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Mouhsin M Shafi
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sydney S Cash
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Daniel B Hoch
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Andrew J Cole
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Eric S Rosenthal
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sahar F Zafar
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jimeng Sun
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - M Brandon Westover
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL.
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Fung FW, Carpenter JL, Chapman KE, Gallentine W, Giza CC, Goldstein JL, Hahn CD, Loddenkemper T, Matsumoto JH, Press CA, Riviello JJ, Abend NS. Survey of Pediatric ICU EEG Monitoring-Reassessment After a Decade. J Clin Neurophysiol 2023; Publish Ahead of Print:00004691-990000000-00075. [PMID: 36930237 PMCID: PMC10504411 DOI: 10.1097/wnp.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
PURPOSE In 2011, the authors conducted a survey regarding continuous EEG (CEEG) utilization in critically ill children. In the interim decade, the literature has expanded, and guidelines and consensus statements have addressed CEEG utilization. Thus, the authors aimed to characterize current practice related to CEEG utilization in critically ill children. METHODS The authors conducted an online survey of pediatric neurologists from 50 US and 12 Canadian institutions in 2022. RESULTS The authors assessed responses from 48 of 62 (77%) surveyed institutions. Reported CEEG indications were consistent with consensus statement recommendations and included altered mental status after a seizure or status epilepticus, altered mental status of unknown etiology, or altered mental status with an acute primary neurological condition. Since the prior survey, there was a 3- to 4-fold increase in the number of patients undergoing CEEG per month and greater use of written pathways for ICU CEEG. However, variability in resources and workflow persisted, particularly regarding technologist availability, frequency of CEEG screening, communication approaches, and electrographic seizure management approaches. CONCLUSIONS Among the surveyed institutions, which included primarily large academic centers, CEEG use in pediatric intensive care units has increased with some practice standardization, but variability in resources and workflow were persistent.
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Affiliation(s)
- France W Fung
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Jessica L Carpenter
- Departments of Pediatrics and Neurology, University of Maryland School of Medicine, Baltimore, Maryland, U.S.A
| | - Kevin E Chapman
- Division of Neurology, Phoenix Children's Hospital and University of Arizona School of Medicine Phoenix, Arizona, U.S.A
| | - William Gallentine
- Division of Neurology, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California, U.S.A
| | - Christopher C Giza
- Division of Neurology, Department of Pediatrics, Mattel Children's Hospital and UCLA Brain Injury Research Center, Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - Joshua L Goldstein
- Division of Neurology, Children's Memorial Hospital and Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Cecil D Hahn
- Division of Neurology, The Hospital for Sick Children and University of Toronto, Toronto, U.S.A
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, U.S.A.; and
| | - Joyce H Matsumoto
- Division of Neurology, Department of Pediatrics, Mattel Children's Hospital and UCLA Brain Injury Research Center, Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - Craig A Press
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - James J Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, U.S.A
| | - Nicholas S Abend
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A
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Loddenkemper T. Detect, predict, and prevent acute seizures and status epilepticus. Epilepsy Behav 2023; 141:109141. [PMID: 36871317 DOI: 10.1016/j.yebeh.2023.109141] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 03/07/2023]
Abstract
Status epilepticus is one of the most frequent pediatric neurological emergencies. While etiology is often influencing the outcome, more easily modifiable risk factors of outcome include detection of prolonged convulsive seizures and status epilepticus and appropriately dosed and timely applied medication treatment. Unpredictability and delayed or incomplete treatment may at times lead to longer seizures, thereby affecting outcomes. Barriers in the care of acute seizures and status epilepticus include the identification of patients at greatest risk of convulsive status epilepticus, potential stigma, distrust, and uncertainties in acute seizure care, including caregivers, physicians, and patients. Furthermore, unpredictability, detection capability, and identification of acute seizures and status epilepticus, limitations in access to obtaining and maintaining appropriate treatment, and rescue treatment options pose challenges. Additionally, timing and dosing of treatment and related acute management algorithms, potential variations in care due to healthcare and physician culture and preference, and factors related to access, equity, diversity, and inclusion of care. We outline strategies for the identification of patients at risk of acute seizures and status epilepticus, improved status epilepticus detection and prediction, and acute closed-loop treatment and status epilepticus prevention. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA 02115, USA.
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7
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Chioma R, Sbordone A, Patti ML, Perri A, Vento G, Nobile S. Applications of Artificial Intelligence in Neonatology. APPLIED SCIENCES 2023; 13:3211. [DOI: 10.3390/app13053211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
The development of artificial intelligence methods has impacted therapeutics, personalized diagnostics, drug discovery, and medical imaging. Although, in many situations, AI clinical decision-support tools may seem superior to rule-based tools, their use may result in additional challenges. Examples include the paucity of large datasets and the presence of unbalanced data (i.e., due to the low occurrence of adverse outcomes), as often seen in neonatal medicine. The most recent and impactful applications of AI in neonatal medicine are discussed in this review, highlighting future research directions relating to the neonatal population. Current AI applications tested in neonatology include tools for vital signs monitoring, disease prediction (respiratory distress syndrome, bronchopulmonary dysplasia, apnea of prematurity) and risk stratification (retinopathy of prematurity, intestinal perforation, jaundice), neurological diagnostic and prognostic support (electroencephalograms, sleep stage classification, neuroimaging), and novel image recognition technologies, which are particularly useful for prompt recognition of infections. To have these kinds of tools helping neonatologists in daily clinical practice could be something extremely revolutionary in the next future. On the other hand, it is important to recognize the limitations of AI to ensure the proper use of this technology.
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Affiliation(s)
- Roberto Chioma
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Annamaria Sbordone
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Maria Letizia Patti
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Alessandro Perri
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giovanni Vento
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Stefano Nobile
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
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8
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Waak M, Laing J, Nagarajan L, Lawn N, Harvey AS. Continuous electroencephalography in the intensive care unit: A critical review and position statement from an Australian and New Zealand perspective. CRIT CARE RESUSC 2023; 25:9-19. [PMID: 37876987 PMCID: PMC10581281 DOI: 10.1016/j.ccrj.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objectives This article aims to critically review the literature on continuous electroencephalography (cEEG) monitoring in the intensive care unit (ICU) from an Australian and New Zealand perspective and provide recommendations for clinicians. Design and review methods A taskforce of adult and paediatric neurologists, selected by the Epilepsy Society of Australia, reviewed the literature on cEEG for seizure detection in critically ill neonates, children, and adults in the ICU. The literature on routine EEG and cEEG for other indications was not reviewed. Following an evaluation of the evidence and discussion of controversial issues, consensus was reached, and a document that highlighted important clinical, practical, and economic considerations regarding cEEG in Australia and New Zealand was drafted. Results This review represents a summary of the literature and consensus opinion regarding the use of cEEG in the ICU for detection of seizures, highlighting gaps in evidence, practical problems with implementation, funding shortfalls, and areas for future research. Conclusion While cEEG detects electrographic seizures in a significant proportion of at-risk neonates, children, and adults in the ICU, conferring poorer neurological outcomes and guiding treatment in many settings, the health economic benefits of treating such seizures remain to be proven. Presently, cEEG in Australian and New Zealand ICUs is a largely unfunded clinical resource that is subsequently reserved for the highest-impact patient groups. Wider adoption of cEEG requires further research into impact on functional and health economic outcomes, education and training of the neurology and ICU teams involved, and securement of the necessary resources and funding to support the service.
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Affiliation(s)
- Michaela Waak
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Joshua Laing
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
- Comprehensive Epilepsy Program, Alfred Health, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Lakshmi Nagarajan
- Department of Neurology, Perth Children's Hospital, Perth, Australia
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Australia
| | - Nicholas Lawn
- Western Australian Adult Epilepsy Service, Sir Charles Gardiner Hospital, Perth, Australia
| | - A. Simon Harvey
- Department of Neurology, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Neurosciences Research Group, Murdoch Children's Research Institute, Melbourne, Australia
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9
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Sporadic and Periodic Interictal Discharges in Critically Ill Children: Seizure Associations and Time to Seizure Identification. J Clin Neurophysiol 2023; 40:130-135. [PMID: 34144575 DOI: 10.1097/wnp.0000000000000860] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE We evaluated interictal discharges (IEDs) as a biomarker for the time to development of electrographic seizures (ES). METHODS Prospective observational study of 254 critically ill children who underwent continuous electroencephalography (cEEG) monitoring. We excluded neonates and patients with known epilepsy or the sole cEEG indication to characterize events. Interictal discharges included sporadic epileptiform discharges and periodic and rhythmic patterns. Sporadic epileptiform discharges were categorized as low frequency (rare [<1/hour] and occasional [≥1/hour but <1/minute]) and high frequency (frequent, [≥1/minute] and abundant [≥1/10 seconds]). Time variables included time from cEEG start to first IED and time between first IED and ES. RESULTS Interictal discharges were present in 33% (83/254) of patients. We identified ES in 20% (50/254), and 86% (43/50) had IEDs. High-frequency sporadic epileptiform discharges (odds ratio [OR], 35; 95% confidence interval [CI], 14.5-88; P < 0.0001) and lateralized periodic discharges (OR, 27; 95% CI, 7.3-100; P < 0.0001) were associated with ES. Mildly abnormal EEG background without IEDs or background asymmetry was associated with the absence of seizures (OR, 0.1; 95% CI, 0.04-0.3; P < 0.0001). Time from cEEG start to first IED was 36 minutes (interquartile range, 3-131 minutes), and time between first IED and ES was 9.6 minutes (interquartile range, 0.6-165 minutes). CONCLUSIONS Interictal discharges are associated with ES and are identified in the first 3 hours of cEEG. High-frequency sporadic epileptiform discharges and periodic patterns have the highest risk of ES. Our findings define a window of high seizure risk after the identification of IEDs in which to allocate resources to improve seizure identification and subsequent treatment.
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10
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Gupta N, Baang HY, Barrett W, Reisbig K, Bendlin KA, Coleman SA, Samson K, Taraschenko O. Reducing seizure to needle times in nonconvulsive status epilepticus with multifaceted quality improvement initiatives. Epilepsy Res 2023; 190:107085. [PMID: 36640479 PMCID: PMC9979156 DOI: 10.1016/j.eplepsyres.2023.107085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Delayed management of nonconvulsive status epilepticus (NCSE) can lead to an increased morbidity and mortality. We previously established that inefficient treatment of NCSE at our institution stemmed from delayed initiation of emergent anti-seizure medications (ASM). In the present study, we assessed the trajectories of these time parameters and determined patient outcomes following the specific quality improvement (QI) interventions. METHODS The QI interventions, including the revision of the educational content for trainees and pharmacy workflow optimization were implemented between January 2019 and September 2021 by a dedicated multidisciplinary task force. The times needed to initiate and administer the ASMs for patients with NCSE as well as patient mortality were assessed in comatose and noncomatose patients and compared with the corresponding values prior to the interventions. RESULTS There were 79 occurrences of NCSE in 74 patients. The median time from seizure detection on EEG to the order of the first and second ASM for NCSE was reduced by 4 (p = 0.83) and 8 min (p = 0.52), respectively compared to the times prior to the initiation of interventions. The median times from the order to administration of the first and third ASM for all NCSE occurrences were reduced by 8 and 10 min, respectively (p = 0.28 and p = 0.10). In the present cohort of comatose patients, the median time spent to order the first ASM was reduced by 16.5 min and the time to administer it reduced by 35 min compared to that in our previous study. The overall patient mortality was decreased by 11.1%. SIGNIFICANCE More efficient delivery of rescue ASMs in patients with NCSE and improvement in their mortality can be achieved with multidisciplinary team efforts aimed at streamlining the functioning of pharmacy and strengthening the education of trainees and nurses.
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Affiliation(s)
- Navnika Gupta
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Hae Y Baang
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Wattana Barrett
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Kayli A Bendlin
- Acute Care Pharmacy, Nebraska Medicine Hospital, Omaha, NE, USA
| | - Scott A Coleman
- Acute Care Pharmacy, Nebraska Medicine Hospital, Omaha, NE, USA
| | - Kaeli Samson
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Olga Taraschenko
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA.
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11
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Levetiracetam versus Phenobarbital for Neonatal Seizures: A Retrospective Cohort Study. Pediatr Neurol 2023; 138:62-70. [PMID: 36401982 DOI: 10.1016/j.pediatrneurol.2022.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/22/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although phenobarbital (PB) is commonly used as a first-line antiseizure medication (ASM) for neonatal seizures, in 2015 we chose to replace it with levetiracetam (LEV), a third-generation ASM. Here, we compared the safety and efficacy of LEV and PB as first-line ASM, considering the years before and after modifying our treatment protocol. METHODS We conducted a retrospective cohort study of 108 neonates with electroencephalography (EEG)-confirmed seizures treated with first-line LEV or PB in 2012 to 2020. RESULTS First-line ASM was LEV in 33 (31%) and PB in 75 (69%) neonates. The etiology included acute symptomatic seizures in 69% of cases (30% hypoxic-ischemic encephalopathy, 32% structural vascular, 6% infectious, otherwise metabolic) and neonatal epilepsy in 22% (5% structural due to brain malformation, 17% genetic). Forty-two of 108 (39%) neonates reached seizure freedom following first-line therapy. Treatment response did not vary by first-line ASM among all neonates, those with acute symptomatic seizures, or those with neonatal-onset epilepsy. Treatment response was lowest for neonates with a higher seizure frequency, particularly for those with status epilepticus versus rare seizures (P < 0.001), irrespective of gestational age, etiology, or EEG findings. Adverse events were noted in 22 neonates treated with PB and in only one treated with LEV (P < 0.001). CONCLUSIONS Our study suggests a potential noninferiority and a more acceptable safety profile for LEV, which may thus be a reasonable option as first-line ASM for neonatal seizures in place of PB. Treatment should be initiated as early as possible since higher seizure frequencies predispose to less favorable responses.
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12
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Implementation of a Pediatric Neurocritical Care Program for Children With Status Epilepticus: Adherence to Continuous Electroencephalogram Monitoring. Pediatr Crit Care Med 2022; 23:1037-1046. [PMID: 36200780 DOI: 10.1097/pcc.0000000000003090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To describe adherence to continuous electroencephalogram (cEEG) monitoring as part of a pediatric neurocritical care (PNCC) program for status epilepticus (SE). DESIGN Retrospective review of pre- and postintervention cohorts. SETTING A pediatric referral hospital. PATIENTS Children admitted to the PICU for SE. INTERVENTIONS We restructured the care delivery model to include a pediatric neurointensive care unit (neuro-ICU) and expanded the cEEG capacity. We created a criteria-based cEEG pathway. We provided education to all providers including the nursing staff. MEASUREMENTS AND MAIN RESULTS The main outcomes were: 1) the percentages of children meeting American Clinical Neurophysiology Society (ACNS) criteria who underwent cEEG monitoring and 2) the time interval between PICU arrival and cEEG initiation. PICU admissions with the diagnosis of SE from May 2017 to December 2017 served as the baseline, which was compared with the same periods in 2018 to 2020 (PNCC era).There were 60 admissions in the pre-PNCC period (2017), 111 in 2018, 118 in 2019, and 108 in 2020. The percentages of admissions from each period that met ACNS criteria for cEEG monitoring were between 84% and 97%. In the pre-PNCC era, 22 of 52 (42%) admissions meeting ACNS criteria underwent cEEG monitoring. In the PNCC era, greater than or equal to 80% of the qualified admissions underwent cEEG monitoring (74/93 [80%] in 2018, 94/115 [82%] in 2019, and 87/101 [86%] in 2020). Compared with the pre-PNCC era, the neuro-ICU had a shorter interval between PICU arrival and cEEG initiation (216 min [141-1,444 min] vs 138 min [103-211 min]). CONCLUSIONS The implementation of a PNCC program with initiatives in care delivery, allocation of resources, and education was associated with increased adherence to best care practices for the management of SE.
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Langton RL, Sharma S, Tiarks GC, Bassuk AG, Glykys J. Lacosamide decreases neonatal seizures without increasing apoptosis. Epilepsia 2022; 63:3051-3065. [PMID: 36168798 PMCID: PMC9742288 DOI: 10.1111/epi.17423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/26/2022] [Accepted: 09/26/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Many seizing neonates fail to respond to first-line anticonvulsant medications. Phenobarbital, an allosteric modulator of γ-aminobutyric acid type A (GABAA ) receptors, has low efficacy in treating neonatal seizures and causes neuronal apoptosis. Nonetheless, it is one of the most used anticonvulsants in this age group. In neonatal mice, phenobarbital's poor effectiveness is due in part to high intraneuronal chloride concentration, which causes GABA to exert depolarizing actions. Therefore, another approach to treat neonatal seizures could be to use anticonvulsants that do not rely on GABAergic modulation. We evaluated whether lacosamide decreases seizures in neonatal mice and whether it increases apoptosis in vitro and in vivo. METHODS In vitro, we measured the effect of different lacosamide concentrations on seizure-like activity induced by the pro-convulsant drug 4-aminopyridine in neocortical brain slices (layer IV/V) from neonatal (postnatal day 8-11) and adult (1-1.6 months old) C57BL/6J mice. In vivo, we recorded the effect of different lacosamide concentrations on neonatal behavioral seizures induced by kainic acid. We studied neocortical apoptosis in vitro and in vivo, measuring terminal deoxynucleotidyl transferase (TdT) dUTP nick-end labeling signal and cleaved-caspase 3. RESULTS Lacosamide reduced epileptiform activity in neocortical brain slices of neonates and adults in a concentration-dependent manner. In vivo, lacosamide reduced the duration and number of behavioral seizures. Lacosamide did not increase total or neuronal apoptosis in the neocortex in vitro or in vivo. SIGNIFICANCE Lacosamide reduces neocortical seizure-like activity in neonatal mice in vitro and in vivo without an acute increase in apoptosis. Our results support the use of lacosamide to treat neonatal seizures, with the advantage of not increasing apoptosis acutely.
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Affiliation(s)
- Rachel L Langton
- Department of Pediatrics, Division of Child Neurology, University of Iowa, Iowa City, Iowa, USA.,Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA
| | - Shaunik Sharma
- Department of Pediatrics, Division of Child Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Grant C Tiarks
- Department of Pediatrics, Division of Child Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Alexander G Bassuk
- Department of Pediatrics, Division of Child Neurology, University of Iowa, Iowa City, Iowa, USA.,Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA.,Department of Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Joseph Glykys
- Department of Pediatrics, Division of Child Neurology, University of Iowa, Iowa City, Iowa, USA.,Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA.,Department of Neurology, University of Iowa, Iowa City, Iowa, USA
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Waak M, Gibbons K, Sparkes L, Harnischfeger J, Gurr S, Schibler A, Slater A, Malone S. Real-time seizure detection in paediatric intensive care patients: the RESET child brain protocol. BMJ Open 2022; 12:e059301. [PMID: 36691237 PMCID: PMC9171209 DOI: 10.1136/bmjopen-2021-059301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/19/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Approximately 20%-40% of comatose children with risk factors in intensive care have electrographic-only seizures; these go unrecognised due to the absence of continuous electroencephalography (EEG) monitoring (cEEG). Utility of cEEG with high-quality assessment is currently limited due to high-resource requirements. New software analysis tools are available to facilitate bedside cEEG assessment using quantitative EEG (QEEG) trends. The primary aim of this study is to describe accuracy of interpretation of QEEG trends by paediatric intensive care unit (PICU) nurses compared with cEEG assessment by neurologist (standard clinical care) in children at risk of seizures and status epilepticus utilising diagnostic test statistics. The secondary aims are to determine time to seizure detection for QEEG users compared with standard clinical care and describe impact of confounders on accuracy of seizure detection. METHODS AND ANALYSIS This will be a single-centre, prospective observational cohort study evaluating a paediatric QEEG programme utilising the full 19 electrode set. The setting will be a 36-bed quaternary PICU with medical, cardiac and general surgical cases. cEEG studies in PICU patients identified as 'at risk of seizures' will be analysed. Trained bedside clinical nurses will interpret the QEEG. Seizure events will be marked as seizures if >3 QEEG criteria occur. Post-hoc dedicated neurologists, who remain blinded to the QEEG analysis, will interpret the cEEG. Determination of standard test characteristics will assess the primary hypothesis. To calculate 95% (CIs) around the sensitivity and specificity estimates with a CI width of 10%, the sample size needed for sensitivity is 80 patients assuming each EEG will have approximately 9 to 18 1-hour epochs. ETHICS AND DISSEMINATION The study has received approval by the Children's Health Queensland Human Research Ethics Committee (HREC/19/QCHQ/58145). Results will be made available to the funders, critical care survivors and their caregivers, the relevant societies, and other researchers. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ANZCTR) 12621001471875.
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Affiliation(s)
- Michaela Waak
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
- Centre for Children's Health Research, Brisbane, Queensland, Australia
| | - Kristen Gibbons
- Centre for Children's Health Research, Brisbane, Queensland, Australia
- The University of Queensland, Saint Lucia, Queensland, Australia
| | - Louise Sparkes
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
- Centre for Children's Health Research, Brisbane, Queensland, Australia
| | - Jane Harnischfeger
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
| | - Sandra Gurr
- Neurosciences, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Andreas Schibler
- St Andrew's War Memorial Hospital, Spring Hill, Queensland, Australia
| | - Anthony Slater
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
| | - Stephen Malone
- The University of Queensland, Saint Lucia, Queensland, Australia
- Neurosciences, Queensland Children's Hospital, South Brisbane, Queensland, Australia
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15
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Beck J, Grosjean C, Bednarek N, Loron G. Amplitude-Integrated EEG Monitoring in Pediatric Intensive Care: Prognostic Value in Meningitis before One Year of Age. CHILDREN 2022; 9:children9050668. [PMID: 35626845 PMCID: PMC9140190 DOI: 10.3390/children9050668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/30/2022] [Accepted: 05/01/2022] [Indexed: 11/16/2022]
Abstract
Pediatric morbidity from meningitis remains considerable. Preventing complications is a major challenge to improve neurological outcome. Seizures may reveal the meningitis itself or some complications of this disease. Amplitude-integrated electroencephalography (aEEG) is gaining interest for the management of patients with acute neurological distress, beyond the neonatal age. This study aimed at evaluating the predictive value of aEEG monitoring during the acute phase in meningitis among a population of infants hospitalized in the pediatric intensive care unit (PICU), and at assessing the practicability of the technique. AEEG records of 25 infants younger than one year of age hospitalized for meningitis were retrospectively analyzed and correlated to clinical data and outcome. Recording was initiated, on average, within the first six hours for n = 18 (72%) patients, and overall quality was considered as good. Occurrence of seizure, of status epilepticus, and the background pattern were significantly associated with unfavorable neurological outcomes. AEEG may help in the management and prognostic assessment of pediatric meningitis. It is an easily achievable, reliable technique, and allows detection of subclinical seizures with minimal training. However, it is important to consider the limitations of aEEG, and combinate it with conventional EEG for the best accuracy.
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Affiliation(s)
- Jonathan Beck
- Department of Neonatology, Reims University Hospital Alix de Champagne, 51100 Reims, France; (J.B.); (C.G.); (N.B.)
- CReSTIC EA 3804 UFR Sciences Exactes et Naturelles, Campus Moulin de la Housse, Université de Reims Champagne Ardenne, 51100 Reims, France
| | - Cecile Grosjean
- Department of Neonatology, Reims University Hospital Alix de Champagne, 51100 Reims, France; (J.B.); (C.G.); (N.B.)
| | - Nathalie Bednarek
- Department of Neonatology, Reims University Hospital Alix de Champagne, 51100 Reims, France; (J.B.); (C.G.); (N.B.)
- CReSTIC EA 3804 UFR Sciences Exactes et Naturelles, Campus Moulin de la Housse, Université de Reims Champagne Ardenne, 51100 Reims, France
| | - Gauthier Loron
- Department of Neonatology, Reims University Hospital Alix de Champagne, 51100 Reims, France; (J.B.); (C.G.); (N.B.)
- CReSTIC EA 3804 UFR Sciences Exactes et Naturelles, Campus Moulin de la Housse, Université de Reims Champagne Ardenne, 51100 Reims, France
- Correspondence:
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16
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Pavel AM, Rennie JM, de Vries LS, Blennow M, Foran A, Shah DK, Pressler RM, Kapellou O, Dempsey EM, Mathieson SR, Pavlidis E, Weeke LC, Livingstone V, Murray DM, Marnane WP, Boylan GB. Neonatal Seizure Management: Is the Timing of Treatment Critical? J Pediatr 2022; 243:61-68.e2. [PMID: 34626667 PMCID: PMC9067353 DOI: 10.1016/j.jpeds.2021.09.058] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess the impact of the time to treatment of the first electrographic seizure on subsequent seizure burden and describe overall seizure management in a large neonatal cohort. STUDY DESIGN Newborns (36-44 weeks of gestation) requiring electroencephalographic (EEG) monitoring recruited to 2 multicenter European studies were included. Infants who received antiseizure medication exclusively after electrographic seizure onset were grouped based on the time to treatment of the first seizure: antiseizure medication within 1 hour, between 1 and 2 hours, and after 2 hours. Outcomes measured were seizure burden, maximum seizure burden, status epilepticus, number of seizures, and antiseizure medication dose over the first 24 hours after seizure onset. RESULTS Out of 472 newborns recruited, 154 (32.6%) had confirmed electrographic seizures. Sixty-nine infants received antiseizure medication exclusively after the onset of electrographic seizure, including 21 infants within 1 hour of seizure onset, 15 between 1 and 2 hours after seizure onset, and 33 at >2 hours after seizure onset. Significantly lower seizure burden and fewer seizures were noted in the infants treated with antiseizure medication within 1 hour of seizure onset (P = .029 and .035, respectively). Overall, 258 of 472 infants (54.7%) received antiseizure medication during the study period, of whom 40 without electrographic seizures received treatment exclusively during EEG monitoring and 11 with electrographic seizures received no treatment. CONCLUSIONS Treatment of neonatal seizures may be time-critical, but more research is needed to confirm this. Improvements in neonatal seizure diagnosis and treatment are also needed.
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Affiliation(s)
- Andreea M. Pavel
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Janet M. Rennie
- Institute for Women's Health, University College London, London, United Kingdom
| | - Linda S. de Vries
- Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mats Blennow
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden,Division of Pediatrics, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Adrienne Foran
- Department of Neonatal Medicine, Rotunda Hospital, Dublin, Ireland
| | - Divyen K. Shah
- Department of Neonatology, Royal London Hospital, London, United Kingdom,The London School of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Ronit M. Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - Olga Kapellou
- Department of Neonatology, Homerton University Hospital NHS Foundation Trust, London, United Kingdom
| | - Eugene M. Dempsey
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Sean R. Mathieson
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Elena Pavlidis
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Lauren C. Weeke
- Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Vicki Livingstone
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Deirdre M. Murray
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - William P. Marnane
- INFANT Research Centre, Cork, Ireland,Department of Electrical & Electronic Engineering, School of Engineering, University College Cork, Cork, Ireland
| | - Geraldine B. Boylan
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland,Reprint requests: Geraldine B. Boylan, PhD, INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Paediatric Academic Unit, 2nd Floor, Cork University Hospital, Wilton, Cork, Ireland T12 DFK4
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17
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Identifying Barriers to Care in the Pediatric Acute Seizure Care Pathway. Int J Integr Care 2022; 22:28. [PMID: 35431702 PMCID: PMC8973859 DOI: 10.5334/ijic.5598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/19/2022] [Indexed: 12/02/2022] Open
Abstract
Objective: We aimed to describe the acute seizure care pathway for pediatric patients and identify barriers encountered by those involved in seizure care management. We also proposed interventions to bridge these care gaps within this pathway. Methods: We constructed a process map that illustrates the acute seizure care pathway for pediatric patients at Boston Children’s Hospital (BCH). The map was designed from knowledge gathered from unstructured interviews with experts at BCH, direct observation of patient care management at BCH through a quality improvement implemented seizure diary and from findings through three studies conducted at BCH, including a prospective observational study by the pediatric Status Epilepticus Research Group, a multi-site international consortium. We also reviewed the literature highlighting gaps and strategies in seizure care management. Results: Within the process map, we identified twenty-nine care gaps encountered by caregivers, care teams, residential and educational institutions, and proposed interventions to address these challenges. The process map outlines clinical care of a patient through the following settings: 1) pre-hospitalization setting, defined as residential and educational settings before hospital admission, 2) BCH emergency department and inpatient settings, 3) post-hospitalization setting, defined as residential and educational settings following hospital discharge or clinic visit and 4) follow-up BCH outpatient settings, including neurology, epilepsy, and primary care provider clinics. The acute seizure care pathway for a pediatric patient who presents with seizures exhibits at least twenty-nine challenges in acute seizure care management. Significance: Identification of care barriers in the acute seizure care pathway provides a necessary first step for implementing interventions and strategies in acute seizure care management that could potentially impact patient outcomes.
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18
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Martin JR, Gabriel P, Gold J, Haas R, Davis S, Gonda D, Sharpe C, Wilson S, Nierenberg N, Scheuer M, Wang S. Optical Flow Estimation Improves Automated Seizure Detection in Neonatal EEG. J Clin Neurophysiol 2022; 39:235-239. [PMID: 32810002 PMCID: PMC7887141 DOI: 10.1097/wnp.0000000000000767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Existing automated seizure detection algorithms report sensitivities between 43% and 77% and specificities between 56% and 90%. The algorithms suffer from false alarms when applied to neonatal EEG because of the high degree of nurse handling and rhythmic patting used to soothe neonates. Computer vision technology that quantifies movement in real time could distinguish artifactual motion and improve automated neonatal seizure detection algorithms. METHODS The authors used video EEG recordings from 43 neonates undergoing monitoring for seizures as part of the NEOLEV2 clinical trial. The Persyst neonatal automated seizure detection algorithm ran in real time during study EEG acquisitions. Computer vision algorithms were applied to extract detailed accounts of artifactual movement of the neonate or people near the neonate though dense optical flow estimation. RESULTS Using the methods mentioned above, 197 periods of patting activity were identified and quantified, of which 45 generated false-positive automated seizure detection events. A binary patting detection algorithm was trained with a subset of 470 event videos. This supervised detection algorithm was applied to a testing subset of 187 event videos with 8 false-positive events, which resulted in a 24% reduction in false-positive automated seizure detections and a 50% reduction in false-positive events caused by neonatal care patting, while maintaining 11 of 12 true-positive seizure detection events. CONCLUSIONS This work presents a novel approach to improving automated seizure detection algorithms used during neonatal video EEG monitoring. This artifact detection mechanism can improve the ability of a seizure detector algorithm to distinguish between artifact and true seizure activity.
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Affiliation(s)
- Joel R Martin
- Department of Electrical Engineering, University of California, San Diego, La Jolla, CA
| | - Paolo Gabriel
- Department of Electrical Engineering, University of California, San Diego, La Jolla, CA
| | - Jeffrey Gold
- Department of Neurosciences, University of California, San Diego, La Jolla, CA
| | - Richard Haas
- Department of Pediatrics, University of California, San Diego, La Jolla, CA
| | - Sue Davis
- Auckland District Health Board, Auckland, New Zealand
| | - David Gonda
- Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Cia Sharpe
- Department of Pediatrics, University of California, San Diego, La Jolla, CA
| | | | | | | | - Sonya Wang
- Department of Neurology, University of Minnesota, Minneapolis, MN
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19
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Barcia Aguilar C, Amengual-Gual M, Sánchez Fernández I, Abend NS, Anderson A, Appavu B, Arya R, Brenton JN, Carpenter JL, Chapman KE, Clark J, Farias-Moeller R, Gaillard WD, Gaínza-Lein M, Glauser T, Goldstein JL, Goodkin HP, Guerriero RM, Huh L, Lai YC, McDonough TL, Mikati MA, Morgan LA, Novotny EJ, Ostendorf A, Payne ET, Peariso K, Piantino J, Riviello J, Sannagowdara K, Sheehan T, Sands TT, Tasker RC, Tchapyjnikov D, Topjian AA, Vasquez A, Wainwright MS, Wilfong AA, Williams K, Loddenkemper T. Time to Treatment in Pediatric Convulsive Refractory Status Epilepticus: The Weekend Effect. Pediatr Neurol 2021; 120:71-79. [PMID: 34022752 DOI: 10.1016/j.pediatrneurol.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/13/2021] [Accepted: 03/19/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Time to treatment in pediatric refractory status epilepticus is delayed. We aimed to evaluate the influence of weekends and holidays on time to treatment of this pediatric emergency. METHODS We performed a retrospective analysis of prospectively collected observational data of pediatric patients with refractory status epilepticus. RESULTS We included 329 patients (56% males) with a median (p25 to p75) age of 3.8 (1.3 to 9) years. The median (p25 to p75) time to first BZD on weekdays and weekends/holidays was 20 (6.8 to 48.3) minutes versus 11 (5 to 35) minutes, P = 0.01; adjusted hazard ratio (HR) = 1.20 (95% confidence interval [CI]: 0.95 to 1.55), P = 0.12. The time to first non-BZD ASM was longer on weekdays than on weekends/holidays (68 [42.8 to 153.5] minutes versus 59 [27 to 120] minutes, P = 0.006; adjusted HR = 1.38 [95% CI: 1.08 to 1.76], P = 0.009). However, this difference was mainly driven by status epilepticus with in-hospital onset: among 108 patients, the time to first non-BZD ASM was longer during weekdays than during weekends/holidays (55.5 [28.8 to 103.5] minutes versus 28 [15.8 to 66.3] minutes, P = 0.003; adjusted HR = 1.65 [95% CI: 1.08 to 2.51], P = 0.01). CONCLUSIONS The time to first non-BZD ASM in pediatric refractory status epilepticus is shorter on weekends/holidays than on weekdays, mainly driven by in-hospital onset status epilepticus. Data on what might be causing this difference may help tailor policies to improve medication application timing.
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Affiliation(s)
- Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Child Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Pediatric Neurology Unit, Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Barcelona, Spain
| | - Nicholas S Abend
- Division of Neurology, The Children's Hospital of Philadelphia, the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne Anderson
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Ravindra Arya
- Division of Pediatric Neurology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - J Nicholas Brenton
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia
| | - Jessica L Carpenter
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Kevin E Chapman
- Departments of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Justice Clark
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Raquel Farias-Moeller
- Department of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William D Gaillard
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Marina Gaínza-Lein
- Instituto de Pediatría, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil, Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago, Chile
| | - Tracy Glauser
- Division of Pediatric Neurology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joshua L Goldstein
- Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Howard P Goodkin
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia
| | - Rejean M Guerriero
- Division of Pediatric and Developmental Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Linda Huh
- Department of Pediatrics, British Columbia Children's Hospital, the University of British Columbia, BC, Canada
| | - Yi-Chen Lai
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Tiffani L McDonough
- Division of Neurology and Epilepsy, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, North Carolina
| | - Lyndsey A Morgan
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington
| | - Edward J Novotny
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington
| | - Adam Ostendorf
- Division of Pediatric Neurology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Eric T Payne
- Division of Neurology, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Katrina Peariso
- Division of Pediatric Neurology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Juan Piantino
- Department of Neurology, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - James Riviello
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kumar Sannagowdara
- Department of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Theodore Sheehan
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tristan T Sands
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Robert C Tasker
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dmitry Tchapyjnikov
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, North Carolina
| | - Alexis A Topjian
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Child and Adolescent Neurology, Mayo Clinic, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Mark S Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington
| | - Angus A Wilfong
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Korwyn Williams
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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20
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Wusthoff CJ, Sundaram V, Abend NS, Massey SL, Lemmon ME, Thomas C, McCulloch CE, Chang T, Soul JS, Chu CJ, Rogers EE, Bonifacio SL, Cilio MR, Glass HC, Shellhaas RA. Seizure Control in Neonates Undergoing Screening vs Confirmatory EEG Monitoring. Neurology 2021; 97:e587-e596. [PMID: 34078719 PMCID: PMC8424499 DOI: 10.1212/wnl.0000000000012293] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 05/03/2021] [Indexed: 12/02/2022] Open
Abstract
Objective To determine whether screening continuous EEG monitoring (cEEG) is associated with greater odds of treatment success for neonatal seizures. Methods We included term neonates with acute symptomatic seizures enrolled in the Neonatal Seizure Registry (NSR), a prospective, multicenter cohort of neonates with seizures. We compared 2 cEEG approaches: (1) screening cEEG, initiated for indications of encephalopathy or paralysis without suspected clinical seizures; and (2) confirmatory cEEG, initiated for the indication of clinical events suspicious for seizures, either alone or in addition to other indications. The primary outcome was successful response to initial seizure treatment, defined as seizures resolved without recurrence within 30 minutes after initial loading dose of antiseizure medicine. Multivariable logistic regression analyses assessed the association between cEEG approach and successful seizure treatment. Results Among 514 neonates included, 161 (31%) had screening cEEG and 353 (69%) had confirmatory cEEG. Neonates with screening cEEG had a higher proportion of successful initial seizure treatment than neonates with confirmatory cEEG (39% vs 18%; p < 0.0001). After adjusting for covariates, there remained a greater odds ratio (OR) for successful initial seizure treatment in the screening vs confirmatory cEEG groups (adjusted OR 2.44, 95% confidence interval 1.45–4.11, p = 0.0008). Conclusions These findings provide evidence from a large, contemporary cohort of neonates that a screening cEEG approach may improve odds of successful treatment of acute seizures. Classification of Evidence This study provides Class III evidence that for neonates a screening cEEG approach, compared to a confirmatory EEG approach, increases the probability of successful treatment of acute seizures.
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Affiliation(s)
- Courtney J Wusthoff
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor.
| | - Vandana Sundaram
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Nicholas S Abend
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Shavonne L Massey
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Monica E Lemmon
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Cameron Thomas
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Charles E McCulloch
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Taeun Chang
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Janet S Soul
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Catherine J Chu
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Elizabeth E Rogers
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Sonia Lomeli Bonifacio
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Maria Roberta Cilio
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Hannah C Glass
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Renée A Shellhaas
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
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Fung FW, Wang Z, Parikh DS, Jacobwitz M, Vala L, Donnelly M, Topjian AA, Xiao R, Abend NS. Electrographic Seizures and Outcome in Critically Ill Children. Neurology 2021; 96:e2749-e2760. [PMID: 33893203 PMCID: PMC8205469 DOI: 10.1212/wnl.0000000000012032] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 03/04/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the association between electroencephalographic seizure (ES) and electroencephalographic status epilepticus (ESE) exposure and unfavorable neurobehavioral outcomes in critically ill children with acute encephalopathy. METHODS This was a prospective cohort study of acutely encephalopathic critically ill children undergoing continuous EEG monitoring (CEEG). ES exposure was assessed as (1) no ES/ESE, (2) ES, or (3) ESE. Outcomes assessed at discharge included the Glasgow Outcome Scale-Extended Pediatric Version (GOS-E-Peds), Pediatric Cerebral Performance Category (PCPC), and mortality. Unfavorable outcome was defined as a reduction in GOS-E-Peds or PCPC score from preadmission to discharge. Stepwise selection was used to generate multivariate logistic regression models that assessed associations between ES exposure and outcomes while adjusting for multiple other variables. RESULTS Among 719 consecutive critically ill patients, there was no evidence of ES in 535 patients (74.4%), ES occurred in 140 patients (19.5%), and ESE in 44 patients (6.1%). The final multivariable logistic regression analyses included ES exposure, age dichotomized at 1 year, acute encephalopathy category, initial EEG background category, comatose at CEEG initiation, and Pediatric Index of Mortality 2 score. There was an association between ESE and unfavorable GOS-E-Peds (odds ratio 2.21, 95% confidence interval 1.07-4.54) and PCPC (odds ratio 2.17, 95% confidence interval 1.05-4.51) but not mortality. There was no association between ES and unfavorable outcome or mortality. CONCLUSIONS Among acutely encephalopathic critically ill children, there was an association between ESE and unfavorable neurobehavioral outcomes, but no association between ESE and mortality. ES exposure was not associated with unfavorable neurobehavioral outcomes or mortality.
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Affiliation(s)
- France W Fung
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA.
| | - Zi Wang
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Darshana S Parikh
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Marin Jacobwitz
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Lisa Vala
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Maureen Donnelly
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Alexis A Topjian
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Rui Xiao
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Nicholas S Abend
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
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22
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Pharmacotherapy for Nonconvulsive Seizures and Nonconvulsive Status Epilepticus. Drugs 2021; 81:749-770. [PMID: 33830480 DOI: 10.1007/s40265-021-01502-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 12/22/2022]
Abstract
Most seizures in critically ill patients are nonconvulsive. A significant number of neurological and medical conditions can be complicated by nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE), with brain infections, hemorrhages, global hypoxia, sepsis, and recent neurosurgery being the most prominent etiologies. Prolonged NCSs and NCSE can lead to adverse neurological outcomes. Early recognition requires a high degree of suspicion and rapid and appropriate duration of continuous electroencephalogram (cEEG) monitoring. Although high quality research evaluating treatment with antiseizure medications and long-term outcome is still lacking, it is probable that expeditious pharmacological management of NCSs and NCSE may prevent refractoriness and further neurological injury. There is limited evidence on pharmacotherapy for NCSs and NCSE, although a few clinical trials encompassing both convulsive and NCSE have demonstrated similar efficacy of different intravenous (IV) antiseizure medications (ASMs), including levetiracetam, valproate, lacosamide and fosphenytoin. The choice of specific ASMs lies on tolerability and safety since critically ill patients frequently have impaired renal and/or hepatic function as well as hematological/hemodynamic lability. Treatment frequently requires more than one ASM and occasionally escalation to IV anesthetic drugs. When multiple ASMs are required, combining different mechanisms of action should be considered. There are several enteral ASMs that could be used when IV ASM options have been exhausted. Refractory NCSE is not uncommon, and its treatment requires a very judicious selection of ASMs aiming at reducing seizure burden along with management of the underlying condition.
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Machine learning models to predict electroencephalographic seizures in critically ill children. Seizure 2021; 87:61-68. [PMID: 33714840 DOI: 10.1016/j.seizure.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/23/2020] [Accepted: 03/02/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To determine whether machine learning techniques would enhance our ability to incorporate key variables into a parsimonious model with optimized prediction performance for electroencephalographic seizure (ES) prediction in critically ill children. METHODS We analyzed data from a prospective observational cohort study of 719 consecutive critically ill children with encephalopathy who underwent clinically-indicated continuous EEG monitoring (CEEG). We implemented and compared three state-of-the-art machine learning methods for ES prediction: (1) random forest; (2) Least Absolute Shrinkage and Selection Operator (LASSO); and (3) Deep Learning Important FeaTures (DeepLIFT). We developed a ranking algorithm based on the relative importance of each variable derived from the machine learning methods. RESULTS Based on our ranking algorithm, the top five variables for ES prediction were: (1) epileptiform discharges in the initial 30 minutes, (2) clinical seizures prior to CEEG initiation, (3) sex, (4) age dichotomized at 1 year, and (5) epileptic encephalopathy. Compared to the stepwise selection-based approach in logistic regression, the top variables selected by our ranking algorithm were more informative as models utilizing the top variables achieved better prediction performance evaluated by prediction accuracy, AUROC and F1 score. Adding additional variables did not improve and sometimes worsened model performance. CONCLUSION The ranking algorithm was helpful in deriving a parsimonious model for ES prediction with optimal performance. However, application of state-of-the-art machine learning models did not substantially improve model performance compared to prior logistic regression models. Thus, to further improve the ES prediction, we may need to collect more samples and variables that provide additional information.
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Thibault C, Massey SL, Abend NS, Naim MY, Zoraian A, Zuppa AF. Population Pharmacokinetics of Phenobarbital in Neonates and Infants on Extracorporeal Membrane Oxygenation and the Influence of Concomitant Renal Replacement Therapy. J Clin Pharmacol 2020; 61:378-387. [PMID: 32960986 DOI: 10.1002/jcph.1743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/25/2020] [Indexed: 01/20/2023]
Abstract
The objective of this study was to describe the pharmacokinetics (PK) of intravenous phenobarbital in neonates and infants on extracorporeal membrane oxygenation (ECMO) and to provide dosing recommendations in this population. We performed a retrospective single-center PK study of phenobarbital in neonates and infants on ECMO between January 1, 2014, and December 31, 2018. We developed a population PK model using nonlinear mixed-effects modeling, performed simulations using the final PK parameters, and determined optimal dosing based on attainment of peak and trough concentrations between 20 and 40 mg/L. We included 35 subjects with a median (range) age and weight of 14 days (1-154 days) and 3.4 kg (1.6-8.1 kg), respectively. A total of 194 samples were included in the analysis. Five children (14%) contributing 30 samples (16%) were supported by continuous venovenous hemodiafiltration (CVVHDF). A 1-compartment model best described the data. Typical clearance and volume of distribution for a 3.4-kg infant were 0.038 L/h and 3.83 L, respectively. Clearance increased with age and CVVHDF. Although on ECMO, phenobarbital clearance in children on CVVHDF was 6-fold higher than clearance in children without CVVHDF. In typical subjects, a loading dose of 30 mg/kg/dose followed by maintenance doses of 6-7 mg/kg/day administered as divided doses every 12 hours reached goal concentrations. Age did not impact dosing recommendations. However, higher doses were needed in children on CVVHDF. We strongly recommend therapeutic drug monitoring in children on renal replacement therapy (excluding slow continuous ultrafiltration) while on ECMO.
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Affiliation(s)
- Céline Thibault
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexandra Zoraian
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Sánchez Fernández I, Abend NS, Amengual-Gual M, Anderson A, Arya R, Barcia Aguilar C, Brenton JN, Carpenter JL, Chapman KE, Clark J, Farias-Moeller R, Gaillard WD, Gaínza-Lein M, Glauser T, Goldstein J, Goodkin HP, Guerriero RM, Lai YC, McDonough T, Mikati MA, Morgan LA, Novotny E, Payne E, Peariso K, Piantino J, Ostendorf A, Sands TT, Sannagowdara K, Tasker RC, Tchapyjnikov D, Topjian AA, Vasquez A, Wainwright MS, Wilfong A, Williams K, Loddenkemper T. Association of guideline publication and delays to treatment in pediatric status epilepticus. Neurology 2020; 95:e1222-e1235. [PMID: 32611646 PMCID: PMC7538224 DOI: 10.1212/wnl.0000000000010174] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/04/2020] [Indexed: 01/24/2023] Open
Abstract
Objective To determine whether publication of evidence on delays in time to treatment shortens time to treatment in pediatric refractory convulsive status epilepticus (rSE), we compared time to treatment before (2011–2014) and after (2015–2019) publication of evidence of delays in treatment of rSE in the Pediatric Status Epilepticus Research Group (pSERG) as assessed by patient interviews and record review. Methods We performed a retrospective analysis of a prospectively collected dataset from June 2011 to September 2019 on pediatric patients (1 month–21 years of age) with rSE. Results We studied 328 patients (56% male) with median (25th–75th percentile [p25–p75]) age of 3.8 (1.3–9.4) years. There were no differences in the median (p25–p75) time to first benzodiazepine (BZD) (20 [5–52.5] vs 15 [5–38] minutes, p = 0.3919), time to first non-BZD antiseizure medication (68 [34.5–163.5] vs 65 [33–142] minutes, p = 0.7328), and time to first continuous infusion (186 [124.2–571] vs 160 [89.5–495] minutes, p = 0.2236). Among 157 patients with out-of-hospital onset whose time to hospital arrival was available, the proportion who received at least 1 BZD before hospital arrival increased after publication of evidence of delays (41 of 81 [50.6%] vs 57 of 76 [75%], p = 0.0018), and the odds ratio (OR) was also increased in multivariable logistic regression (OR 4.35 [95% confidence interval 1.96–10.3], p = 0.0005). Conclusion Publication of evidence on delays in time to treatment was not associated with improvements in time to treatment of rSE, although it was associated with an increase in the proportion of patients who received at least 1 BZD before hospital arrival.
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Affiliation(s)
- Iván Sánchez Fernández
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Nicholas S Abend
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Marta Amengual-Gual
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Anne Anderson
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Ravindra Arya
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Cristina Barcia Aguilar
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - James Nicholas Brenton
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Jessica L Carpenter
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Kevin E Chapman
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Justice Clark
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Raquel Farias-Moeller
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - William D Gaillard
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Marina Gaínza-Lein
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Tracy Glauser
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Joshua Goldstein
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Howard P Goodkin
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Réjean M Guerriero
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Yi-Chen Lai
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Tiffani McDonough
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Mohamad A Mikati
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Lindsey A Morgan
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Edward Novotny
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Eric Payne
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Katrina Peariso
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Juan Piantino
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Adam Ostendorf
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Tristan T Sands
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Kumar Sannagowdara
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Robert C Tasker
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Dimtry Tchapyjnikov
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Alexis A Topjian
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Alejandra Vasquez
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Mark S Wainwright
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Angus Wilfong
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Kowryn Williams
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix
| | - Tobias Loddenkemper
- From the Division of Epilepsy and Clinical Neurophysiology (I.S.F., M.A.-G., C.B.A., J.C., M.G.-L., A.V., T.L.), Department of Neurology, and Department of Neurology (R.C.T.), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universitat de Barcelona, Spain; Division of Neurology (N.S.A.), Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Pediatric Critical Care Medicine (A.A., Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; University of Virginia Health (J.N.B., H.P.G.), Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatric Neurology (R.F.-M., K.S.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Instituto de Pediatría (M.G.-L.), Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.G., T.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric and Developmental Neurology (R.M.G.), Department of Neurology, Washington University School of Medicine, St. Louis, MO; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Pediatrics and Neurology (L.A.M., E.N., M.S.W.), Seattle Children's Hospital, University of Washington; Center for Integrative Brain Research (L.A.M., E.N., M.S.W.), Seattle Children's Research Institute, WA; Department of Neurology (E.P.), Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurology (J.P.), Doernbercher Children's Hospital, Oregon Health & Science University, Portland; Department of Neurology (A.O.), Nationwide Children's Hospital, Ohio State University, Columbus; Division of Child Neurology and Institute for Genomic Medicine (T.T.S.), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York; Division of Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Division of Child and Adolescent Neurology (A.V.), Department of Neurology, Mayo Clinic, Rochester, MN; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix.
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Griffith JL, Tomko ST, Guerriero RM. Continuous Electroencephalography Monitoring in Critically Ill Infants and Children. Pediatr Neurol 2020; 108:40-46. [PMID: 32446643 DOI: 10.1016/j.pediatrneurol.2020.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022]
Abstract
Continuous video electroencephalography (CEEG) monitoring of critically ill infants and children has expanded rapidly in recent years. Indications for CEEG include evaluation of patients with altered mental status, characterization of paroxysmal events, and detection of electrographic seizures, including monitoring of patients with limited neurological examination or conditions that put them at high risk for electrographic seizures (e.g., cardiac arrest or extracorporeal membrane oxygenation cannulation). Depending on the inclusion criteria and clinical characteristics of the population studied, the percentage of pediatric patients with electrographic seizures varies from 7% to 46% and with electrographic status epilepticus from 1% to 23%. There is also evidence that epileptiform and background CEEG patterns may provide important information about prognosis in certain clinical populations. Quantitative EEG techniques are emerging as a tool to enhance the value of CEEG to provide real-time bedside data for management and prognosis. Continued research is needed to understand the clinical value of seizure detection and identification of other CEEG patterns on the outcomes of critically ill infants and children.
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Affiliation(s)
- Jennifer L Griffith
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri.
| | - Stuart T Tomko
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Réjean M Guerriero
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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Sharpe C, Reiner GE, Davis SL, Nespeca M, Gold JJ, Rasmussen M, Kuperman R, Harbert MJ, Michelson D, Joe P, Wang S, Rismanchi N, Le NM, Mower A, Kim J, Battin MR, Lane B, Honold J, Knodel E, Arnell K, Bridge R, Lee L, Ernstrom K, Raman R, Haas RH. Levetiracetam Versus Phenobarbital for Neonatal Seizures: A Randomized Controlled Trial. Pediatrics 2020; 145:peds.2019-3182. [PMID: 32385134 PMCID: PMC7263056 DOI: 10.1542/peds.2019-3182] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There are no US Food and Drug Administration-approved therapies for neonatal seizures. Phenobarbital and phenytoin frequently fail to control seizures. There are concerns about the safety of seizure medications in the developing brain. Levetiracetam has proven efficacy and an excellent safety profile in older patients; therefore, there is great interest in its use in neonates. However, randomized studies have not been performed. Our objectives were to study the efficacy and safety of levetiracetam compared with phenobarbital as a first-line treatment of neonatal seizures. METHODS The study was a multicenter, randomized, blinded, controlled, phase IIb trial investigating the efficacy and safety of levetiracetam compared with phenobarbital as a first-line treatment for neonatal seizures of any cause. The primary outcome measure was complete seizure freedom for 24 hours, assessed by independent review of the EEGs by 2 neurophysiologists. RESULTS Eighty percent of patients (24 of 30) randomly assigned to phenobarbital remained seizure free for 24 hours, compared with 28% of patients (15 of 53) randomly assigned to levetiracetam (P < .001; relative risk 0.35 [95% confidence interval: 0.22-0.56]; modified intention-to-treat population). A 7.5% improvement in efficacy was achieved with a dose escalation of levetiracetam from 40 to 60 mg/kg. More adverse effects were seen in subjects randomly assigned to phenobarbital (not statistically significant). CONCLUSIONS In this phase IIb study, phenobarbital was more effective than levetiracetam for the treatment of neonatal seizures. Higher rates of adverse effects were seen with phenobarbital treatment. Higher-dose studies of levetiracetam are warranted, and definitive studies with long-term outcome measures are needed.
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Affiliation(s)
- Cynthia Sharpe
- Department of Paediatric Neurology, Starship Children’s Health, Auckland, New Zealand;,Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | - Gail E. Reiner
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | - Suzanne L. Davis
- Department of Paediatric Neurology, Starship Children’s Health, Auckland, New Zealand
| | - Mark Nespeca
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | - Jeffrey J. Gold
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | | | - Rachel Kuperman
- Pediatric Neurology, University of California, San Francisco Benioff Children’s Hospital Oakland, Oakland, California
| | - Mary Jo Harbert
- Department of Neurosciences, School of Medicine, University of California, San Diego and Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - David Michelson
- Division of Pediatric Neurology, Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, California
| | - Priscilla Joe
- Division of Neonatology, Departments of Pediatrics and
| | - Sonya Wang
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | - Neggy Rismanchi
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | - Ngoc Minh Le
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Andrew Mower
- Department of Neurology, Children’s Hospital of Orange County, Orange, California
| | - Jae Kim
- Division of NeoNatology, Departments of Pediatrics and
| | - Malcolm R. Battin
- Department of Neonatology, Auckland District Health Board, Auckland, New Zealand; and
| | - Brian Lane
- Division of Neonatology, Departments of Pediatrics, University of California, San Diego and Rady Children's Hospital San Diego, San Diego, California
| | - Jose Honold
- Division of Neonatology, Departments of Pediatrics, University of California, San Diego and Rady Children's Hospital San Diego, San Diego, California
| | - Ellen Knodel
- Division of Neonatology, Departments of Pediatrics, University of California, San Diego and Rady Children's Hospital San Diego, San Diego, California
| | - Kathy Arnell
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Renee Bridge
- Division of NeoNatology, Departments of Pediatrics and
| | - Lilly Lee
- Neurosciences, School of Medicine, University of California, San Diego, San Diego, California
| | - Karin Ernstrom
- Alzheimer’s Therapeutic Research Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Rema Raman
- Alzheimer’s Therapeutic Research Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Richard H. Haas
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
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Thibault C, Naim MY, Abend NS, Licht DJ, Gaynor JW, Xiao R, Massey SL. A retrospective comparison of phenobarbital and levetiracetam for the treatment of seizures following cardiac surgery in neonates. Epilepsia 2020; 61:627-635. [PMID: 32162678 DOI: 10.1111/epi.16469] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/07/2020] [Accepted: 02/13/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To compare the safety and efficacy of phenobarbital and levetiracetam in a cohort of neonates with seizures following cardiac surgery. METHODS We performed a retrospective single-center study of consecutive neonates with electrographically confirmed seizures managed with antiseizure medication after cardiac surgery from June 15, 2012 to December 31, 2018. We compared the safety and efficacy of phenobarbital and levetiracetam as first-line therapy. RESULTS First-line therapy was phenobarbital in 31 neonates and levetiracetam in 22 neonates. Phenobarbital was associated with more adverse events (P = .006). Eight neonates (14%) experienced an adverse event related to phenobarbital use, including seven with hypotension and one with respiratory depression. No adverse events were reported with levetiracetam use. The cessation of electrographic seizures was similar in both groups, including 18 neonates (58%) with seizure cessation after phenobarbital and 12 neonates (55%) with seizure cessation after levetiracetam (P = 1.0). The combined cessation rates of phenobarbital and levetiracetam when used as first- or second-line therapy were 58% and 47%, respectively (P = .47). SIGNIFICANCE Phenobarbital was associated with more adverse events than levetiracetam, and the two drugs were equally but incompletely effective in treating electrographically confirmed seizures in neonates following cardiac surgery. Given its more acceptable safety profile and potential noninferiority, levetiracetam may be a reasonable option for first-line therapy for treatment of seizures in this population. Further prospective studies are needed to confirm these results.
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Affiliation(s)
- Céline Thibault
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nicholas S Abend
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel J Licht
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
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Electroencephalographic Reporting for Refractory Status Epilepticus. J Clin Neurophysiol 2019; 36:365-370. [PMID: 31166226 DOI: 10.1097/wnp.0000000000000595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE We aimed to determine whether clinical EEG reports obtained from children in the intensive care unit with refractory status epilepticus could provide data for comparative effectiveness research studies. METHODS We conducted a retrospective descriptive study to assess the documentation of key variables within clinical continuous EEG monitoring reports based on the American Clinical Neurophysiology Society's standardized EEG terminology for children with refractory status epilepticus from 10 academic centers. Two pediatric electroencephalographers reviewed the EEG reports. We compared reports generated using free text or templates. RESULTS We reviewed 191 EEG reports. Agreement between the electroencephalographers regarding whether a variable was described in the report ranged from fair to very good. The presence of electrographic seizures (ES) was documented in 46% (87/191) of reports, and these reports documented the time of first ES in 64% (56/87), ES duration in 72% (63/85), and ES frequency in 68% (59/87). Reactivity was documented in 16% (31/191) of reports, and it was more often documented in template than in free-text reports (40% vs. 14%, P = 0.006). Other variables were not differentially reported in template versus free-text reports. CONCLUSIONS Many key EEG features are not documented consistently in clinical continuous EEG monitoring reports, including ES characteristics and reactivity assessment. Standardization may be needed for clinical EEG reports to provide informative data for large multicenter observational studies.
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Fung FW, Jacobwitz M, Vala L, Parikh D, Donnelly M, Xiao R, Topjian AA, Abend NS. Electroencephalographic seizures in critically ill children: Management and adverse events. Epilepsia 2019; 60:2095-2104. [PMID: 31538340 DOI: 10.1111/epi.16341] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/27/2019] [Accepted: 08/27/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Guidelines recommend that encephalopathic critically ill children undergo continuous electroencephalographic (CEEG) monitoring for electrographic seizure (ES) identification and management. However, limited data exist on antiseizure medication (ASM) safety for ES treatment in critically ill children. METHODS We performed a single-center prospective observational study of encephalopathic critically ill children undergoing CEEG. Clinical and EEG features and ASM utilization patterns were evaluated. We determined the incidence, types, and risk factors for adverse events associated with ASM administration. RESULTS A total of 472 consecutive critically ill children undergoing CEEG were enrolled. ES occurred in 131 children (28%). Clinicians administered ASM to 108 children with ES (82%). ES terminated after the initial ASM in 38% of patients who received one ASM, after the second ASM in 35% of patients who received two ASMs, after the third ASM in 50% of patients who received three ASMs, and after the fourth ASM in 53% of patients who received four ASMs. Thirty patients (28%) received anesthetic infusions for ES management. Adverse events occurred in 18 patients (17%). Adverse effects were expected and resolved in all patients, and they were generally serious (in 15 patients) and definitely related (in 12 patients). Adverse events were rare in patients with acute symptomatic seizures requiring only one to two ASMs for treatment, but were more common in children with epilepsy, ictal-interictal continuum EEG patterns, or patients requiring more extensive ASM management. SIGNIFICANCE ES ceased after one ASM in only 38% of critically ill children but ceased after two ASMs in 73% of critically ill children. Thus, ES management was often accomplished with readily available medications, but optimization of multistep ES management strategies might be beneficial. Adverse events were rare and manageable in children with acute symptomatic seizures requiring only one to two ASMs for treatment. Future studies are needed to determine whether management of acute symptomatic ES improves neurobehavioral outcomes.
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Affiliation(s)
- France W Fung
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia,, Philadelphia, PA, USA.,Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marin Jacobwitz
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia,, Philadelphia, PA, USA
| | - Lisa Vala
- Department of Neurodiagnostics, Children's Hospital of Philadelphia,, Philadelphia, PA, USA
| | - Darshana Parikh
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia,, Philadelphia, PA, USA.,Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maureen Donnelly
- Department of Neurodiagnostics, Children's Hospital of Philadelphia,, Philadelphia, PA, USA
| | - Rui Xiao
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Anesthesia & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nicholas S Abend
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia,, Philadelphia, PA, USA.,Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Neurodiagnostics, Children's Hospital of Philadelphia,, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Anesthesia & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Towards Successes in the Management of Nonconvulsive Status Epilepticus: Tracing the Detection-to-Needle Trajectories. J Clin Neurophysiol 2019; 37:253-258. [PMID: 31490288 DOI: 10.1097/wnp.0000000000000630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Data on the timeliness of emergent medication delivery for nonconvulsive status epilepticus (NCSE) are currently lacking. METHODS Retrospective chart reviews (between 2015 and 2018) and analyses of all patients with NCSE were performed at the University of Nebraska Medical Center, a level 4 epilepsy center, to determine the latencies to order and administration of the first, second, and third antiepileptic drugs (AEDs). Recurrent NCSE cases were considered independently and classified as comatose and noncomatose. RESULTS There were 77 occurrences of NCSE in 53 patients. The first, second, and third AEDs were delivered with substantial delays at median times of 80 (25%-75% interquartile range, 44-166), 126 (interquartile range, 67-239), and 158 minutes (interquartile range, 89-295), respectively, from seizure detection. The median times to the order of the first and second AEDs were 33 and 134.5 minutes longer in comatose NCSE patients compared with those with noncomatose forms, respectively (P = 0.001 and 0.004, respectively). The median times between the AED orders and their administration in these two groups were the same (P = 0.60 and 0.37, respectively). With bivariate analysis, the median latencies to administration of the first, second, and third AEDs were significantly increased by 33, 109.5, and 173 minutes, respectively, in patients who died within 30 days compared with those who survived (P = 0.047, P = 0.02, P = 0.0007, respectively). CONCLUSIONS The administration of the first, second, and third AEDs for NCSE was delayed. Slow initiation of acute treatment in comatose patients was caused by delays in the placement of the medication order.
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Analysis of a Low-Cost EEG Monitoring System and Dry Electrodes toward Clinical Use in the Neonatal ICU. SENSORS 2019; 19:s19112637. [PMID: 31212613 PMCID: PMC6603568 DOI: 10.3390/s19112637] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/03/2019] [Accepted: 06/09/2019] [Indexed: 11/24/2022]
Abstract
Electroencephalography (EEG) is an important clinical tool for monitoring neurological health. However, the required equipment, expertise, and patient preparation inhibits its use outside of tertiary care. Non-experts struggle to obtain high-quality EEG due to its low amplitude and artefact susceptibility. Wet electrodes are currently used, which require abrasive/conductive gels to reduce skin-electrode impedance. Advances in dry electrodes, which do not require gels, have simplified this process. However, the assessment of dry electrodes on neonates is limited due to health and safety barriers. This study presents a simulation framework for assessing the quality of EEG systems using a neonatal EEG database, without the use of human participants. The framework is used to evaluate a low-cost EEG acquisition system and compare performance of wet and dry (Micro Transdermal Interface Platforms (MicroTIPs), g.tec-g.SAHARA) electrodes using accurately acquired impedance models. A separate experiment assessing the electrodes on adult participants was conducted to verify the simulation framework’s efficacy. Dry electrodes have higher impedance than wet electrodes, causing a reduction in signal quality. However, MicroTIPs perform comparably to wet electrodes at the frontal region and g.tec-g.SAHARA performs well at the occipital region. Using the simulation framework, a 25dB signal-to-noise ratio (SNR) was obtained for the low-cost EEG system. The tests on adults closely matched the simulated results.
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Assessing the Feasibility of Providing a Real-Time Response to Seizures Detected With Continuous Long-Term Neonatal Electroencephalography Monitoring. J Clin Neurophysiol 2019; 36:9-13. [PMID: 30289769 DOI: 10.1097/wnp.0000000000000525] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Continuous video electroencephalography (cEEG) monitoring is the recommended gold standard of care for at-risk neonates but is not available in many Neonatal Intensive Care Units (NICUs). To conduct a randomized treatment trial of levetiracetam for the first-line treatment of neonatal seizures (the NEOLEV2 trial), we developed a monitoring infrastructure at five NICUs, implementing recent technological advancements to provide continuous video EEG monitoring and real-time response to seizure detection. Here, we report on the feasibility of providing this level of care. METHODS Twenty-five key informant interviews were conducted with study neurologists, neonatologists, coordinators, and EEG technicians from the commercial EEG monitoring company Corticare. A general inductive approach was used to analyze these qualitative data. RESULTS A robust infrastructure for continuous video EEG monitoring, remote review, and real-time seizure detection was established at all sites. At the time of this survey, 260 babies had been recruited and monitored for 2 to 6 days. The EEG technician review by the commercial EEG monitoring company was reassuring to families and neonatologists and led to earlier detection of seizures but did not reduce work load for neurologists. Neurologists found the automated neonatal seizure detector algorithm provided by the EEG software company Persyst useful, but the accuracy of the algorithm was not such that it could be used without review by human expert. Placement of EEG electrodes to initiate monitoring, especially after hours, remains problematic. CONCLUSIONS Technological advancements have made it possible to provide at-risk neonates with continuous video EEG monitoring, real-time detection of and response to seizures. However, this standard of care remains unfeasible in usual clinical practice. Chief obstacles remain starting a recording and resourcing the real-time specialist review of suspect seizures.
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Conventional and quantitative EEG in status epilepticus. Seizure 2018; 68:38-45. [PMID: 30528098 DOI: 10.1016/j.seizure.2018.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/11/2018] [Accepted: 09/14/2018] [Indexed: 01/10/2023] Open
Abstract
PURPOSE To summarize the use of continuous electroencephalographic monitoring (cEEG) in the diagnosis and management of pediatric convulsive status epilepticus (CSE) and subsequent non-convulsive seizures (NCS) with a focus on available guidelines and infrastructure. In addition, we provide an overview of quantitative EEG (QEEG) for the identification of NCS in critically ill children. METHODS We performed a review of the medical literature on the use of cEEG and QEEG in pediatric CSE. This included published guideline, consensus statements, and literature focused on the use of cEEG and QEEG to detect NCS. RESULTS cEEG monitoring is recommended for prompt recognition of ongoing seizures that may be subtle, masked by pharmacologic paralysis, and or converted from convulsive seizures to NCS after administration of anti-seizure medications. Evidence indicating that high seizure burden is associated with worse outcome has motivated prompt recognition and management of NCS. The American Clinical Neurophysiology Society's consensus statement recommends a minimum of 24 h to exclude electrographic seizures, while the Neurocritical Care Society's guideline suggests 48 h in patients that are comatose. The use of QEEG amongst electroencephalographers and critical care medicine providers is increasing for NCS detection in critically ill children. The sensitivity and specificity of QEEG to detect NCS ranges from 65 to 83% and 65-92%, respectively. CONCLUSION The use of cEEG is important to the diagnosis and treatment of NCS or subtle clinical seizures after pediatric CSE. QEEG allows cEEG data to be reviewed and interpreted quickly and is a useful tool for detection of NCS after CSE.
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Does Continuous Video-EEG in Patients With Altered Consciousness Improve Patient Outcome? Current Evidence and Randomized Controlled Trial Design. J Clin Neurophysiol 2018. [DOI: 10.1097/wnp.0000000000000467] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Towards acute pediatric status epilepticus intervention teams: Do we need “Seizure Codes”? Seizure 2018; 58:133-140. [DOI: 10.1016/j.seizure.2018.04.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/15/2018] [Accepted: 04/12/2018] [Indexed: 12/28/2022] Open
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Massey S, Banwell B. Clinical implications of status epilepticus in children. THE LANCET. CHILD & ADOLESCENT HEALTH 2018; 2:81-83. [PMID: 30169239 DOI: 10.1016/s2352-4642(17)30175-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 06/08/2023]
Affiliation(s)
- Shavonne Massey
- Department of Neurology and Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Brenda Banwell
- Department of Neurology and Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Sánchez Fernández I, Sansevere AJ, Gaínza-Lein M, Buraniqi E, Tasker RC, Loddenkemper T. Time to continuous electroencephalogram in repeated admissions to the pediatric intensive care unit. Seizure 2017; 54:19-26. [PMID: 29182970 DOI: 10.1016/j.seizure.2017.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/14/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Describe timing from intensive care unit (ICU) admission to initiation of continuous electroencephalogram (cEEG) in repeated ICU admissions. METHOD We performed a retrospective observational study in pediatric patients who underwent repeated ICU admissions with cEEG from 2011 to 2013. The main outcome measure was time from ICU admission to cEEG. RESULTS There were 41 patients (54% males) with at least 2 ICU admissions with cEEG (median (p25-p75) age at first admission: 3.3 (0.3-8.4) years, at second admission: 3.9 (1.1-9.4) years), 7 patients (57% males, 9.9 (2.9-11.5) years) with at least 3 ICU admissions, and 5 patients (60% males, 10.1 (4-10.5) years) with at least 4 ICU admissions. One patient had 21 ICU admissions. The median (p25-p75) time from ICU admission to cEEG was not different during the first and second ICU admissions [10.7 (1.9-22.9) hours versus 13 (0.2-36.7) hours; p=0.908]. Among patients with electrographic seizures on first admission, time to cEEG was not different during the first and second admissions [7.9 (0.5-23.4) hours versus 14.5 (-2 to 44.5) hours; p=0.636]. Among patients with status epilepticus during the first admission, time to cEEG was not different between the first and second admissions [15.3 (9-79) hours versus 40.7 (19.3-42.6) hours; p=0.75]. CONCLUSIONS The time from ICU admission to the initiation of cEEG did not decrease in second or subsequent ICU admissions, even in patients with seizures or status epilepticus on the first admission.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Spain
| | - Arnold J Sansevere
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
| | - Ersida Buraniqi
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert C Tasker
- Division of Critical Care, Departments of Neurology, Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Eskioglou E, Stähli C, Rossetti AO, Novy J. Extended EEG and non-convulsive status epilepticus: Benefit over routine EEG? Acta Neurol Scand 2017; 136:272-276. [PMID: 28026006 DOI: 10.1111/ane.12722] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE EEG monitoring is increasingly used in critically ill patients, but impact on clinical outcome remains unclear. We aimed to investigate the benefit of repeated extended EEG in the prognosis of patients with non-convulsive status epilepticus (SE). MATERIALS & METHODS We retrospectively collected 29 consecutive patients with non-convulsive SE without coma, who underwent repeated extended EEG between 2013 and 2015. We compared these patients with an historical age-matched group of 58 patients managed between 2011 and 2013 with routine EEG only. We excluded patients treated with therapeutic coma for SE treatment. Outcome at hospital discharge was categorized as return to baseline conditions, new disability, and death. RESULTS Severity of SE was similar in the two groups, with similar proportion of potential fatal etiologies (58% in the extended EEG group vs 60%, P=.529), similar STESS scores (median was three in both groups, P=.714), and comparable acute hospitalization duration (median of 15 vs 11 days, P=.131). The extended EEG group received slightly more anti-epileptic drugs (median was three in both groups, P=.026). Distribution of the outcome categories at hospital discharge was similar (P=.129). CONCLUSIONS Extended EEG used for the management of non-convulsive status epilepticus does not seem to improve clinical outcome, but is associated with a higher number of prescribed anti-epileptic drugs. The benefit of continuous EEG monitoring in non-convulsive SE without coma SE should be addressed through a randomized trial.
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Affiliation(s)
- E. Eskioglou
- Department of clinical neurosciences; Centre Hospitalier Universitaire Vaudois (CHUV); University of Lausanne; Lausanne Switzerland
| | - C. Stähli
- Department of clinical neurosciences; Centre Hospitalier Universitaire Vaudois (CHUV); University of Lausanne; Lausanne Switzerland
| | - A. O. Rossetti
- Department of clinical neurosciences; Centre Hospitalier Universitaire Vaudois (CHUV); University of Lausanne; Lausanne Switzerland
| | - J. Novy
- Department of clinical neurosciences; Centre Hospitalier Universitaire Vaudois (CHUV); University of Lausanne; Lausanne Switzerland
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Abstract
PURPOSE OF REVIEW Brain-directed critical care for children is a relatively new area of subspecialization in pediatric critical care. Pediatric neurocritical care teams combine the expertise of neurology, neurosurgery, and critical care medicine. The positive impact of delivering specialized care to pediatric patients with acute neurological illness is becoming more apparent, but the optimum way to implement and sustain the delivery of this is complicated and poorly understood. We aim to provide emerging evidence supporting that effective implementation of pediatric neurocritical care pathways can improve patient survival and outcomes. We also provide an overview of the most effective strategies across the field of implementation science that can facilitate deployment of neurocritical care pathways in the pediatric ICU. RECENT FINDINGS Implementation strategies can broadly be grouped according to six categories: planning, educating, restructuring, financing, managing quality, and attending to the policy context. Using a combination of these strategies in the last decade, several institutions have improved patient morbidity and mortality. Although much work remains to be done, emerging evidence supports that implementation of evidence-based care pathways for critically ill children with two common neurological diagnoses - status epilepticus and traumatic brain injury - improves outcomes. SUMMARY Pediatric and neonatal neurocritical care programs that support evidence-based care can be effectively structured using appropriately sequenced implementation strategies to improve outcomes across a variety of patient populations and in a variety of healthcare settings.
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Affiliation(s)
- Christopher Markham
- aDivision of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis Children's Hospital bGeorge Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri, USA
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Sánchez Fernández I, Sansevere AJ, Guerriero RM, Buraniqi E, Pearl PL, Tasker RC, Loddenkemper T. Time to electroencephalography is independently associated with outcome in critically ill neonates and children. Epilepsia 2017; 58:420-428. [PMID: 28130784 DOI: 10.1111/epi.13653] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To identify factors associated with in-hospital mortality in neonates and children undergoing continuous electroencephalography (cEEG) monitoring in the intensive care unit (ICU). METHODS We performed a retrospective observational study in patients from birth to 21 years of age who underwent clinically indicated cEEG in the ICU from 2011 to 2013. The main outcome measure was in-hospital mortality. RESULTS Six-hundred and twenty-five patients (54.2% male) met eligibility criteria, of whom 211 were neonates (55% male, 24.8% premature) and 414 were pediatric patients (53.9% male). Electrographic seizures occurred in 176 patients (28.2%) and status epilepticus (SE) occurred in 20 (11.4%). The time from ICU admission to cEEG initiation was 16.7 (5.1-94.4) h. Eighty-nine patients (14.2%) (30 [14.2%] neonates, and 59 [14.3%] pediatric patients) died in the hospital. In neonates-after controlling for gender and prematurity-independent factors associated with mortality were prematurity (odds ratio [OR] 2.63. 95% confidence interval [CI] 1.06-6.5, p = 0.037), presence of status epilepticus (SE); OR 8.82, 95% CI 1.74-44.57, p = 0.008), and time from ICU admission to initiation of cEEG (OR 1.002, 95% CI 1.001-1.004 per hour, p = 0.008]. In pediatric patients-after controlling for gender and age-independent factors associated with mortality were the absence of seizures factors associated with mortality were absence of seizures (OR = 4.3, (95% CI: 1.5-12.4), p = 0.007), the presence of SE (OR 7.76, 95% CI 1.47-40.91, p = 0.016), and the time from ICU admission to initiation of cEEG (OR 1.001, 95% CI 1.0002-1.001, per hour, p = 0.005]. SIGNIFICANCE Both presence of electrographic SE and time from ICU admission to cEEG initiation were independent factors associated with mortality in neonates and pediatric patients with cEEG in the ICU.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Child Neurology, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Arnold J Sansevere
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Rejean M Guerriero
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Ersida Buraniqi
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Phillip L Pearl
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Robert C Tasker
- Division of Critical Care, Departments of Neurology, Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
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Alvarez V, Rodriguez Ruiz AA, LaRoche S, Hirsch LJ, Parres C, Voinescu PE, Fernandez A, Petroff OA, Rampal N, Haider HA, Lee JW. The use and yield of continuous EEG in critically ill patients: A comparative study of three centers. Clin Neurophysiol 2017; 128:570-578. [PMID: 28231475 DOI: 10.1016/j.clinph.2017.01.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/07/2016] [Accepted: 01/04/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Continuous EEG (cEEG) monitoring of critically ill patients has gained widespread use, but there is substantial reported variability in its use. We analyzed cEEG and antiseizure drug (ASD) usage at three high volume centers. METHODS We utilized a multicenter cEEG database used daily as a clinical reporting tool in three tertiary care sites (Emory Hospital, Brigham and Women's Hospital and Yale - New Haven Hospital). We compared the cEEG usage patterns, seizure frequency, detection of rhythmic/periodic patterns (RPP), and ASD use between the sites. RESULTS 5792 cEEG sessions were analyzed. Indication for cEEG monitoring and recording duration were similar between the sites. Seizures detection rate was nearly identical between the three sites, ranging between 12.3% and 13.6%. Median time to first seizure and detection rate of RPPs were similar. There were significant differences in doses of levetiracetam, valproic acid, and lacosamide used between the three sites. CONCLUSIONS There was remarkable uniformity in seizure detection rates within three high volume centers. In contrast, dose of ASD used frequently differed between the three sites. SIGNIFICANCE These large volume data are in line with recent guidelines regarding cEEG use. Difference in ASD use suggests discrepancies in how cEEG results influence patient management.
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Affiliation(s)
- Vincent Alvarez
- Department of Neurology, Hôpital du Valais, Sion, Switzerland; Department of Clinical Neurosciences, CHUV and University of Lausanne, Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
| | | | | | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher Parres
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Paula E Voinescu
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Andres Fernandez
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ognen A Petroff
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Nishi Rampal
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Utility of electroencephalography: Experience from a U.S. tertiary care medical center. Clin Neurophysiol 2016; 127:3335-40. [DOI: 10.1016/j.clinph.2016.08.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 08/07/2016] [Accepted: 08/17/2016] [Indexed: 11/20/2022]
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