Comparative Outcomes of Levetiracetam and Phenobarbital Usage in the Treatment of Neonatal Seizures: A Retrospective Analysis

OBJECTIVES AND AIM

The primary aim of this study was to conduct a comparative analysis of the safety and efficacy of levetiracetam (LEV) and phenobarbital (PB) as first-line treatments for neonatal seizure management. This study was designed to measure and compare the incidence of adverse effects and to determine the discharge and mortality rates associated with the use of these antiseizure medications (ASMs). Through this comparison, this research sought to provide insights to optimise care for neonates experiencing seizures.

MATERIALS AND METHODS

This retrospective cohort study evaluated 104 neonates treated for seizures at Zeynep Kamil Hospital from 2015 to 2020 after excluding those on non-PB/LEV antiseizure medications. Seizures were characterised using electroencephalogram (EEG) and categorised according to aetiology and frequency. Treatment efficacy was gauged by seizure cessation, as confirmed using EEG. Adverse effects and demographic data were recorded. Statistical analyses were conducted using SPSS, employing the Shapiro-Wilk, independent t-test, Mann-Whitney U test, and chi-square test, with a significance threshold of p < 0.05.

RESULTS

Overall, 104 neonates treated with first-line ASM were evaluated for efficacy; PB was administered in 68.26% of the cases, while LEV was utilised in 31.74%. The total complete response rate was 40.38%, with no significant difference between the PB and LEV groups (p = 0.309). The incidence rate ratios (IRRs) demonstrated that seizure frequency profoundly influenced treatment effectiveness, with IRRs of 2.09 for rare seizures, 3.25 for frequent seizures, and 4.01 for status epilepticus, indicating a higher treatment response rate with increasing seizure frequency. For second-line treatment, among a subset of 62 patients, PB had a slight, non-significant advantage over LEV, with an odds ratio of 1.09, suggesting a marginally better response to LEV. Adverse events were significantly more frequent in the PB group, affecting 19 of 67 neonates (28.36%), compared to only 2 of 71 neonates (2.82%) in the LEV group (p < 0.001). No significant difference was observed in the discharge rates between the two groups (PB, 67.61%; LEV, 75.76%; p = 0.674). Interestingly, the mortality rate was significantly higher in the LEV group (45.45%) than that in the PB group (22.54%; p = 0.045).

CONCLUSION

This study underscores LEV's superior safety profile over PB in neonatal seizure management, evidenced by a significantly lower rate of adverse events. PB seems to be more effective in the second-line treatment of neonatal seizures. Despite the lack of significant differences in the discharge rates, the higher mortality rate associated with LEV warrants further investigation. These findings advocate the cautious selection of antiepileptic drugs in neonatal care, with a preference for LEV based on its safety profile.

Acute and prolonged competing effects of activation history on human motor unit firing rates during contractile impairment and recovery

The purpose of this study was to investigate the effect of inducing post-activation potentiation (PAP) during prolonged low-frequency force depression (PLFFD) on motor unit (MU) firing rates. In 10 participants, grouped firing rates of 3027 MUs from the tibialis anterior were recorded with tungsten microelectrodes. Baseline MU firing rates at 25% isometric maximal voluntary contraction (MVC) were ∼14 Hz. A 1 min dorsiflexion MVC reduced torque and maximal MU firing rates (36 Hz) by 49% and 52%, respectively. Following task completion, firing rates at 25% of baseline MVC torque and torque in response to electrically evoked (single twitch, 10 Hz and 50 Hz) stimulation were assessed before and after a 5 s MVC (to induce PAP) every 10 min for 60 min. From 10 to 60 min after task completion, the torque ratios (twitch:50 Hz and 10:50 Hz) were depressed (∼30%) relative to baseline (P < 0.001), indicating PLFFD; and firing rates were higher by ∼15% relative to baseline (P < 0.001). This occurred despite recovery of MVC rates (∼99%) and torque (∼95%) by 10 min (P > 0.3). Inducing PAP during PLFFD increased both low to high torque ratios (twitch and 10:50 Hz) by ∼200% and ∼135%, respectively (P < 0.001) and firing rates were ∼18% lower relative to PLFFD rates (P < 0.001), despite a speeding of evoked contractile properties (P = 0.001). Thus, firing rates appear strongly matched to alterations in torque, rather than contractile speed when modified by contractile history, and lower rates during PAP may be a mechanism to mitigate effects of PLFFD. The effect of activation history on contractile function demonstrates acute compensatory responses of motoneuron output. KEY POINTS: Prolonged low frequency force depression (PLFFD) following a sustained 1 min isometric maximal voluntary contraction causes an increase in submaximal mean motor unit (MU) firing rates. Inducing post-activation potentiation (PAP) during PLFFD, however, causes a reduction in mean submaximal MU firing rates to a level below those at baseline. The mean firing rate reduction during PAP occurs despite a speeding of evoked contractile properties and thus firing rates are more strongly matched to alterations in torque, rather than contractile speed when modified by various contractile histories. The reductions in firing rates during PAP may mitigate the effects of PLFFD during voluntary contractions. These results demonstrate that firing rates are highly responsive to opposing influences on the contractile state and can make rapid compensatory rate adjustments dependent on the active state of the muscle.

Motor unit firing rates in young and very old adult males during an isokinetic fatiguing task and short-term recovery in the anconeus muscle

Understanding motor unit (MU) properties with muscle fatigue in adult ageing is limited to isometric tasks. The purpose was to investigate the effect of an isokinetic fatiguing task on MU firing rates between two adult age groups of males. Single MUs were recorded by intramuscular electrodes in the anconeus muscle of 8 young (19-33 years) and 11 very old adults (78-93 years). Fatigue was induced by repeated isokinetic maximal voluntary contractions at 25% of maximum velocity (Vmax), until elbow extension power decreased by 35%. At baseline, the very old had lower maximal power (135 vs 214 W, P=0.002) and slower maximal velocity (177 vs 196°/s, P<0.001) compared to young. Despite a similar number of contractions (39 young and 44 very old) to task-failure (P=0.33) the older males were less fatigable as time under tension was ~25% longer (P=0.04). Maximum firing rates from ~ 20 single MUs per age group were tracked continuously throughout the task and during 10-min of recovery. Similar rates were recorded (24.7 and 23.6 Hz, P=0.18) at baseline 25% Vmax, and during the task (23.3 and 28.7% decrease, P=0.21) between young and very old, respectively. Power and MU rates recovered similarly by 2-min of rest in both groups (all P>0.15). Despite differences in baseline capability, very old males in this relatively slow isokinetic task were more fatigue-resistant, but the fatigue-related reduction and recovery in MU rates were similar between groups. Therefore, fatigue in this task between age groups are not differentially affected by alterations in firing rates.

Deficit in knee extension strength following anterior cruciate ligament reconstruction is explained by a reduced neural drive to the vasti muscles

The persistence of quadriceps weakness represents a major concern following anterior cruciate ligament reconstruction (ACLR). The underlying adaptations occurring in the activity of spinal motoneurons are still unexplored. This study examined the discharge patterns of large populations of motor units (MUs) in the vastus lateralis (VL) and vastus medialis muscles following ACLR. Nine ACLR individuals and 10 controls performed unilateral trapezoidal contractions of the knee extensor muscles at 35%, 50% and 70% of the maximal voluntary isometric force (MVIF). High-density surface electromyography (HDsEMG) was used to record the myoelectrical activity of the vasti muscles in both limbs. HDsEMG signals were decomposed with a convolutive blind source separation method and MU properties were extracted and compared between sides and groups. The ACLR group showed a lower MVIF on the reconstructed side compared to the contralateral side (28.1%; P < 0.001). This force deficit was accompanied by reduced MU discharge rates (∼21%; P < 0.05), lower absolute MU recruitment and derecruitment thresholds (∼22% and ∼22.5%, respectively; P < 0.05) and lower input-output gain of motoneurons (27.3%; P = 0.009). Deficits in MU discharge rates of the VL and in absolute recruitment and derecruitment thresholds of both vasti MUs were associated with deficits in MVIF (P < 0.05). A strong between-side correlation was found for MU discharge rates of the VL of ACLR individuals (P < 0.01). There were no significant between-group differences (P > 0.05). These results indicate that mid- to long-term strength deficits following ACLR may be attributable to a reduced neural drive to vasti muscles, with potential changes in excitatory and inhibitory synaptic inputs. KEY POINTS: Impaired expression and control of knee extension forces is common after anterior cruciate ligament reconstruction and is related to high risk of a second injury. To provide novel insights into the neural basis of this impairment, the discharge patterns of motor units in the vastus lateralis and vastus medialis were investigated during voluntary force contractions. There was lower knee extensor strength on the reconstructed side with respect to the contralateral side, which was explained by deficits in motor unit discharge rate and an altered motoneuronal input-output gain. Insufficient excitatory inputs to motoneurons and increased inhibitory afferent signals potentially contributed to these alterations. These results further our understanding of the neural underpinnings of quadriceps weakness following anterior cruciate ligament reconstruction and can help to develop effective rehabilitation protocols to regain muscle strength and reduce the risk of a second injury.

Anconeus motor unit firing rates during isometric and muscle-shortening contractions comparing young and very old adults

With effects of aging, voluntary neural drive to the muscle, measured as motor unit (MU) firing rate, is lower in older adults during sustained isometric contractions compared with young adults, but differences remain unknown during limb movements. Therefore, our purpose was to compare MU firing rates during both isometric and shortening contractions between two adult age groups. We analyzed intramuscular electromyography of single-MU recordings in the anconeus muscle of young (n = 8, 19-33 yr) and very old (n = 13, 78-93 yr) male adults during maximal voluntary contractions (MVCs). In sustained isometric and muscle-shortening contractions during limb movement, MU trains were linked with elbow joint kinematic parameters throughout the contraction time course. The older group was 33% weaker and 10% slower during movements than the young group (P < 0.01). In isometric contractions, median firing rates were 42% lower (P < 0.01) in the older group (18 Hz) compared with the young group (31 Hz), but during shortening contractions firing rates were higher for both age groups and not statistically different between groups. As a function of contraction time, firing rates at MU recruitment threshold were 39% lower in the older group, but the firing rate decrease was attenuated threefold throughout shortening contraction compared with the young group. At the single-MU level, age-related differences during isometric contractions (i.e., pre-movement initiation) do not remain constant throughout movement that comprises greater effects of muscle shortening. Results indicate that neural drive is task dependent and during movement in older adults it is decreased minimally.NEW & NOTEWORTHY Changes of neural drive to the muscle with adult aging, measured as motor unit firing rates during limb movements, are unknown. Throughout maximal voluntary efforts we found that, in comparison with young adults, firing rates were lower during isometric contraction in older adults but not different during elbow extension movements. Despite the older group being ∼33% weaker across contractions, their muscles can receive neural drive during movements that are similar to that of younger adults.

Pain-induced changes in motor unit discharge depend on recruitment threshold and contraction speed

At high forces, the discharge rates of lower- and higher-threshold motor units (MU) are influenced in a different way by muscle pain. These differential effects may be particularly important for performing contractions at different speeds since the proportion of lower- and higher-threshold MUs recruited varies with contraction velocity. We investigated whether MU discharge and recruitment strategies are differentially affected by pain depending on their recruitment threshold (RT), across a range of contraction speeds. Participants performed ankle dorsiflexion sinusoidal-isometric contractions at two frequencies (0.25 and 1 Hz) and two modulation amplitudes [5% and 10% of the maximum voluntary contraction (MVC)] with a mean target torque of 20%MVC. High-density surface electromyography recordings from the tibialis anterior muscle were decomposed and the same MUs were tracked across painful (hypertonic saline injection) and nonpainful conditions. Torque variability, mean discharge rate (MDR), DR variability (DRvar), RT, and the delay between the cumulative spike train and the resultant torque output (neuromechanical delay, NMD) were assessed. The average RT was greater at faster contraction velocities (P = 0.01) but was not affected by pain. At the fastest contraction speed, torque variability and DRvar were reduced (P < 0.05) and MDR was maintained. Conversely, MDR decreased and DRvar and NMD increased significantly during pain at slow contraction speeds (P < 0.05). These results show that reductions in contraction amplitude and increased recruitment of higher-threshold MUs at fast contraction speeds appear to compensate for the inhibitory effect of nociceptive inputs on lower-threshold MUs, allowing the exertion of fast submaximal contractions during pain.NEW & NOTEWORTHY Pain induces changes in motor performance, motor unit recruitment, and rate coding behavior that varies across different contraction speeds. Here we show that that pain reduces motor unit discharge rate and prolongs the neuromechanical delay at slow contraction speeds only. This new evidence suggests that there are differential nociceptive inhibitory effects across the motor unit pool, which allows fast submaximal contractions to be exerted despite the presence of pain.

COVID-19 patients' clinical characteristics, discharge rate, and fatality rate of meta-analysis

The aim of this study was to analyze the clinical data, discharge rate, and fatality rate of COVID‐19 patients for clinical help. The clinical data of COVID‐19 patients from December 2019 to February 2020 were retrieved from four databases. We statistically analyzed the clinical symptoms and laboratory results of COVID‐19 patients and explained the discharge rate and fatality rate with a single‐arm meta‐analysis. The available data of 1994 patients in 10 literatures were included in our study. The main clinical symptoms of COVID‐19 patients were fever (88.5%), cough (68.6%), myalgia or fatigue (35.8%), expectoration (28.2%), and dyspnea (21.9%). Minor symptoms include headache or dizziness (12.1%), diarrhea (4.8%), nausea and vomiting (3.9%). The results of the laboratory showed that the lymphocytopenia (64.5%), increase of C‐reactive protein (44.3%), increase of lactic dehydrogenase (28.3%), and leukocytopenia (29.4%) were more common. The results of single‐arm meta‐analysis showed that the male took a larger percentage in the gender distribution of COVID‐19 patients 60% (95% CI [0.54, 0.65]), the discharge rate of COVID‐19 patients was 52% (95% CI [0.34,0.70]), and the fatality rate was 5% (95% CI [0.01,0.11]).

Our study explored the clinical and epidemiological characteristics of COVID‐19 patients, and proposed the need to focus on other systemic symptoms such as the gastrointestinal tract firstly, which could be of use for clinical work.

Differential Modulation of Motor Unit Properties from the Separate Components of the Triceps Surae in Humans

The triceps surae is comprised of the soleus, and medial (MG) and lateral (LG) gastrocnemii. Modulation of triceps surae motor units (MUs) is context- and muscle-dependent, yet it is unknown how the disparate components of the triceps surae work together to achieve the common goal of high-intensity voluntary isometric plantar flexion torque gradation. Thus, the purpose was to assess the interrelationships between MU recruitment thresholds (MURTs) and MU discharge rates (MUDRs) among these three muscles during contractions from low to high intensities. We sampled 157 MU action potential trains from the MG (68), LG (38) and soleus (51) using fine-wire intramuscular electromyography (EMG) during voluntary ramp isometric contractions up to 100% maximal voluntary contraction (MVC). The soleus exhibited 41% and 54% lower MURTs compared to the MG (p < 0.0001) and LG (p < 0.0001), respectively, whereas MG MURTs were 22% lower than the LG (p < 0.0001). Initial MUDRs were 35% and 26% greater for the LG compared with the MG (p < 0.0001) and soleus (p < 0.0001), but no difference was detected between the MG and soleus (p = 0.28). Finally, initial MUDRs displayed a positive relationship with MURTs for each independent triceps surae component (p ≤ 0.002). The relative differences in MU properties of each muscle in this synergistic group illustrate that MU control strategies are likely optimized with respect to the relative contribution of each muscle to plantar flexion torque or functional roles.

Temporal Coding of Single Auditory Nerve Fibers Is Not Degraded in Aging Gerbils

People suffering from age-related hearing loss typically present with deficits in temporal processing tasks. Temporal processing deficits have also been shown in single-unit studies at the level of the auditory brainstem, midbrain, and cortex of aged animals. In this study, we explored whether temporal coding is already affected at the level of the input to the central auditory system. Single-unit auditory nerve fiber recordings were obtained from 41 Mongolian gerbils of either sex, divided between young, middle-aged, and old gerbils. Temporal coding quality was evaluated as vector strength in response to tones at best frequency, and by constructing shuffled and cross-stimulus autocorrelograms, and reverse correlations, from responses to 1 s noise bursts at 10-30 dB sensation level (dB above threshold). At comparable sensation levels, all measures showed that temporal coding was not altered in auditory nerve fibers of aging gerbils. Furthermore, both temporal fine structure and envelope coding remained unaffected. However, spontaneous rates were decreased in aging gerbils. Importantly, despite elevated pure tone thresholds, the frequency tuning of auditory nerve fibers was not affected. These results suggest that age-related temporal coding deficits arise more centrally, possibly due to a loss of auditory nerve fibers (or their peripheral synapses) but not due to qualitative changes in the responses of remaining auditory nerve fibers. The reduced spontaneous rate and elevated thresholds, but normal frequency tuning, of aged auditory nerve fibers can be explained by the well known reduction of endocochlear potential due to strial dysfunction in aged gerbils.SIGNIFICANCE STATEMENT As our society ages, age-related hearing deficits become ever more prevalent. Apart from decreased hearing sensitivity, elderly people often suffer from a reduced ability to communicate in daily settings, which is thought to be caused by known age-related deficits in auditory temporal processing. The current study demonstrated, using several different stimuli and analysis techniques, that these putative temporal processing deficits are not apparent in responses of single-unit auditory nerve fibers of quiet-aged gerbils. This suggests that age-related temporal processing deficits may develop more central to the auditory nerve, possibly due to a reduced population of active auditory nerve fibers, which will be of importance for the development of treatments for age-related hearing disorders.

Temporal Coding of Single Auditory Nerve Fibers Is Not Degraded in Aging Gerbils

People suffering from age-related hearing loss typically present with deficits in temporal processing tasks. Temporal processing deficits have also been shown in single-unit studies at the level of the auditory brainstem, midbrain, and cortex of aged animals. In this study, we explored whether temporal coding is already affected at the level of the input to the central auditory system. Single-unit auditory nerve fiber recordings were obtained from 41 Mongolian gerbils of either sex, divided between young, middle-aged, and old gerbils. Temporal coding quality was evaluated as vector strength in response to tones at best frequency, and by constructing shuffled and cross-stimulus autocorrelograms, and reverse correlations, from responses to 1 s noise bursts at 10-30 dB sensation level (dB above threshold). At comparable sensation levels, all measures showed that temporal coding was not altered in auditory nerve fibers of aging gerbils. Furthermore, both temporal fine structure and envelope coding remained unaffected. However, spontaneous rates were decreased in aging gerbils. Importantly, despite elevated pure tone thresholds, the frequency tuning of auditory nerve fibers was not affected. These results suggest that age-related temporal coding deficits arise more centrally, possibly due to a loss of auditory nerve fibers (or their peripheral synapses) but not due to qualitative changes in the responses of remaining auditory nerve fibers. The reduced spontaneous rate and elevated thresholds, but normal frequency tuning, of aged auditory nerve fibers can be explained by the well known reduction of endocochlear potential due to strial dysfunction in aged gerbils.SIGNIFICANCE STATEMENT As our society ages, age-related hearing deficits become ever more prevalent. Apart from decreased hearing sensitivity, elderly people often suffer from a reduced ability to communicate in daily settings, which is thought to be caused by known age-related deficits in auditory temporal processing. The current study demonstrated, using several different stimuli and analysis techniques, that these putative temporal processing deficits are not apparent in responses of single-unit auditory nerve fibers of quiet-aged gerbils. This suggests that age-related temporal processing deficits may develop more central to the auditory nerve, possibly due to a reduced population of active auditory nerve fibers, which will be of importance for the development of treatments for age-related hearing disorders.

Correlation between discharge timings of pairs of motor units reveals the presence but not the proportion of common synaptic input to motor neurons

We investigated whether correlation measures derived from pairs of motor unit (MU) spike trains are reliable indicators of the degree of common synaptic input to motor neurons. Several 50-s isometric contractions of the biceps brachii muscle were performed at different target forces ranging from 10 to 30% of the maximal voluntary contraction relying on force feedback. Forty-eight pairs of MUs were examined at various force levels. Motor unit synchrony was assessed by cross-correlation analysis using three indexes: the output correlation as the peak of the cross-histogram (ρ) and the number of synchronous spikes per second (CIS) and per trigger (E). Individual analysis of MU pairs revealed that ρ, CIS, and E were most often positively associated with discharge rate (87, 85, and 76% of the MU pairs, respectively) and negatively with interspike interval variability (69, 65, and 62% of the MU pairs, respectively). Moreover, the behavior of synchronization indexes with discharge rate (and interspike interval variability) varied greatly among the MU pairs. These results were consistent with theoretical predictions, which showed that the output correlation between pairs of spike trains depends on the statistics of the input current and motor neuron intrinsic properties that differ for different motor neuron pairs. In conclusion, the synchronization between MU firing trains is necessarily caused by the (functional) common input to motor neurons, but it is not possible to infer the degree of shared common input to a pair of motor neurons on the basis of correlation measures of their output spike trains.NEW & NOTEWORTHY The strength of correlation between output spike trains is only poorly associated with the degree of common input to the population of motor neurons. The synchronization between motor unit firing trains is necessarily caused by the (functional) common input to motor neurons, but it is not possible to infer the degree of shared common input to a pair of motor neurons on the basis of correlation measures of their output spike trains.

Rate modulation of human anconeus motor units during high-intensity dynamic elbow extensions

Investigations of high-intensity isometric fatiguing protocols report decreases in motor unit firing rates (MUFRs), but little is known regarding changes in MUFRs following fatigue induced by high-intensity dynamic contractions. Our purpose was to evaluate MUFRs of the anconeus (an accessory elbow extensor) and elbow extension power production as a function of time to task failure (TTF) during high-velocity fatiguing concentric contractions against a moderately heavy resistance. Fine-wire intramuscular electrode pairs were inserted into the anconeus to record MUs in 12 male participants (25 ± 3 yr), over repeated sessions on separate days. MUs were tracked throughout a three-stage, varying load dynamic elbow extension protocol designed to extend the task duration for >1 min thereby inducing substantial fatigue. Mean MUFRs and peak power were calculated for three relative time ranges: 0-15% TTF (beginning), 45-60% TTF (middle) and 85-100% TTF (end). Mean duration of the overall fatigue protocol was ∼80 s. Following the protocol, isometric maximum voluntary contraction (MVC), highest velocity at 35% MVC load, and peak power decreased 37, 60, and 64% compared with baseline, respectively. Data from 20 anconeus MUs tracked successfully throughout the protocol indicated a reduction in MUFRs in relation to power loss from 36 Hz/160 W (0-15% TTF) to 28 Hz/97 W (45-60% TTF) to 23 Hz/43 W (85-100% TTF). During these high-intensity maximal effort concentric contractions, anconeus MUFRs decreased substantially (>35%). Although the absolute MUFRs were higher in the present study than those reported previously for other muscles during sustained high-intensity isometric tasks, the relative decrease in MUFRs was similar between the two tasks.