Learning difficulties often not documented in newly diagnosed focal epilepsy

OBJECTIVE

A previous investigation of people with newly diagnosed focal epilepsy participating in the Human Epilepsy Project 1 (HEP1) revealed an association between learning difficulties and structural brain differences, suggesting an underlying relationship prior to seizure onset. To investigate physicians' practices of documentation learning difficulties during clinical encounters, we conducted a review of initial epileptologist encounter notes from HEP1 participants who self-reported early life learning difficulties separately as part of study enrollment.

METHODS

HEP1 enrolled 67 North American participants between June 2012 and November 2017 who self-reported one or more difficulties with learning (i.e., having repeated grade, receiving learning support/remediation, and/or formal diagnosis of a learning disability) prior to epilepsy diagnosis as part of the study enrollment. The epileptologist's initial encounter note was then reviewed in detail for each of these participants. Documentation of learning issues and specific diagnoses of learning disabilities was compared to participant characteristics. Regression analysis was used to test for any independent associations between participant characteristics and physician documentation of learning difficulties.

RESULTS

There were significant independent relationships between age, sex, and physician documentation of learning difficulties. On average, participants ages 22 and younger were 12.12 times more likely to have their learning difficulties documented compared to those 23 years and older (95 % CI: 2.226 to 66.02, p = 0.004). Additionally, male participants had 7.2 times greater odds of having their learning difficulty documented compared to female participants (95 % CI: 1.538 to 33.717, p = 0.012). There were no significant independent associations between race, language, employment, or geographical region.

SIGNIFICANCE

These findings highlight disparities in physician documentation for people with newly diagnosed focal epilepsy and a history of learning difficulties. In the HEP1 cohort, physicians were more likely to document learning difficulties in males and in younger individuals. Systematic practice standards are important for reducing healthcare disparities across populations, improving clinical care to individuals, as well as enabling more accurate retrospective study of clinical phenomenon.

Long-term seizure diary tracking habits in clinical studies: Evidence from the Human Epilepsy Project

OBJECTIVE

To characterize seizure tracking patterns of people with focal epilepsy using electronic seizure diary entries, and to assess for risk factors associated with poor tracking.

METHODS

We analyzed electronic seizure diary data from 410 participants with newly diagnosed focal epilepsy in the Human Epilepsy Project 1 (HEP1). Each participant was expected to record data each day during the study, regardless of seizure occurrence. The primary outcome of this post-hoc analysis was whether each participant properly tracked a seizure diary entry each day during their study participation. Using finite mixture modeling, we grouped patient tracking trajectories into data-driven clusters. Once defined, we used multinomial modeling to test for independent risk factors of tracking group membership.

RESULTS

Using over up to three years of daily seizure diary data per subject, we found four distinct seizure tracking groups: consistent, frequent at study onset, occasional, and rare. Participants in the consistent tracking group tracked a median of 92% (interquartile range, IQR: 82%, 99%) of expected days, compared to 47% (IQR:34%, 60%) in the frequent at study onset group, 37% (IQR: 26%, 49%) in the occasional group, and 9% (IQR: 3%, 15%) in the rare group. In multivariable analysis, consistent trackers had lower rates of seizure days per tracked year during their study participation, compared to other groups.

SIGNIFICANCE

Future efforts need to focus on improving seizure diary tracking adherence to improve quality of outcome data, particularly in those with higher seizure burden. In addition, accounting for missing data when using seizure diary data as a primary outcome is important in research trials. If not properly accounted for, total seizure burden may be underestimated and biased, skewing results of clinical trials.

Improving epilepsy diagnosis across the lifespan: approaches and innovations

Epilepsy diagnosis is often delayed or inaccurate, exposing people to ongoing seizures and their substantial consequences until effective treatment is initiated. Important factors contributing to this problem include delayed recognition of seizure symptoms by patients and eyewitnesses; cultural, geographical, and financial barriers to seeking health care; and missed or delayed diagnosis by health-care providers. Epilepsy diagnosis involves several steps. The first step is recognition of epileptic seizures; next is classification of epilepsy type and whether an epilepsy syndrome is present; finally, the underlying epilepsy-associated comorbidities and potential causes must be identified, which differ across the lifespan. Clinical history, elicited from patients and eyewitnesses, is a fundamental component of the diagnostic pathway. Recent technological advances, including smartphone videography and genetic testing, are increasingly used in routine practice. Innovations in technology, such as artificial intelligence, could provide new possibilities for directly and indirectly detecting epilepsy and might make valuable contributions to diagnostic algorithms in the future.

Unrecognized Focal Nonmotor Seizures in Adolescents Presenting to Emergency Departments

BACKGROUND AND OBJECTIVES

Many adolescents with undiagnosed focal epilepsy seek evaluation in emergency departments (EDs). Accurate history-taking is essential to prompt diagnosis and treatment. In this study, we investigated ED recognition of motor vs nonmotor seizures and its effect on management and treatment of focal epilepsy in adolescents.

METHODS

This was a retrospective analysis of enrollment data from the Human Epilepsy Project (HEP), an international multi-institutional study that collected data from 34 sites between 2012 and 2017. Participants were 12 years or older, neurotypical, and within 4 months of treatment initiation for focal epilepsy. We used HEP enrollment medical records to review participants' initial diagnosis and management.

RESULTS

A total of 83 adolescents were enrolled between 12 and 18 years. Fifty-eight (70%) presented to an ED before diagnosis of epilepsy. Although most ED presentations were for motor seizures (n = 52; 90%), many patients had a history of nonmotor seizures (20/52 or 38%). Adolescents with initial nonmotor seizures were less likely to present to EDs (26/44 or 59% vs 32/39 or 82%, p = 0.02), and nonmotor seizures were less likely to be correctly identified (2/6 or 33% vs 42/52 or 81%, p = 0.008). A history of initial nonmotor seizures was not recognized in any adolescent who presented for a first-lifetime motor seizure. As a result, initiation of treatment and admission from the ED was not more likely for these adolescents who met the definition of epilepsy compared with those with no seizure history. This lack of nonmotor seizure history recognition in the ED was greater than that observed in the adult group (0% vs 23%, p = 0.03) and occurred in both pediatric and nonpediatric ED settings.

DISCUSSION

Our study supports growing evidence that nonmotor seizures are often undiagnosed, with many individuals coming to attention only after conversion to motor seizures. We found this treatment gap is exacerbated in the adolescent population. Our study highlights a critical need for physicians to inquire about the symptoms of nonmotor seizures, even when the presenting seizure is motor. Future interventions should focus on improving nonmotor seizure recognition for this population in EDs.

Testing the diagnostic accuracy of common questions for seizure diagnosis: Challenges and future directions

OBJECTIVE

The aim of this study was to evaluate the diagnostic accuracy of common interview questions used to distinguish a diagnosis of epilepsy from seizure mimics including non-epileptic seizures (NES), migraine, and syncope.

METHODS

200 outpatients were recruited with an established diagnosis of focal epilepsy (n = 50), NES (n = 50), migraine (n = 50), and syncope (n = 50). Patients completed an eight-item, yes-or-no online questionnaire about symptoms related to their events. Sensitivity and specificity were calculated. Using a weighted scoring for the questions alone with baseline characteristics, the overall questionnaire was tested for diagnostic accuracy.

RESULTS

Of individual questions, the most sensitive one asked if events are sudden in onset (98 % sensitive for epilepsy (95 % CI: 89 %, 100 %)). The least sensitive question asked if events are stereotyped (46 % sensitive for epilepsy (95 % CI: 32 %, 60 %)). Overall, three of the eight questions showed an association with epilepsy as opposed to mimics. These included questions about "sudden onset" (OR 10.76, 95 % CI: (1.66, 449.21) p = 0.0047), "duration < 5 min" (OR 3.34, 95 % CI: (1.62, 6.89), p = 0.0008), and "duration not > 30 min" (OR 4.44, 95 % CI: (1.94, 11.05), p = <0.0001). When individual seizure mimics were compared to epilepsy, differences in responses were most notable between the epilepsy and migraine patients. Syncope and NES were most similar in responses to epilepsy. The overall weighted questionnaire incorporating patient age and sex produced an area under the ROC curve of 0.80 (95 % CI: 0.74, 0.87)).

CONCLUSION

In this study, we examined the ability of common interview questions used by physicians to distinguish between epilepsy and prevalent epilepsy mimics, specifically NES, migraines, and syncope. Using a weighted scoring system for questions, and including age and sex, produced a sensitive and specific predictive model for the diagnosis of epilepsy. In contrast to many prior studies which evaluated either a large number of questions or used methods with difficult practical application, our study is unique in that we tested a small number of easy-to-understand "yes" or "no" questions that can be implemented in most clinical settings by non-specialists.

Improving Seizure Frequency Documentation and Classification

Background and Objectives

Accurate and reliable seizure data are essential for evaluating treatment strategies and tracking the quality of care in epilepsy clinics. This quality improvement project aimed to increase seizure documentation (i.e., documentation of seizure frequency from 80% to 100%, date of last seizure from 35% to 50%, and International League Against Epilepsy (ILAE) seizure classification from 35% to at least 50%) over 6 months.

Methods

We surveyed 7 epileptologists to determine their perceived seizure frequency, ILAE classification, and date of last seizure documentation habits. Baseline data were collected weekly from September to December 2021. Subsequently, we implemented a newly created flowsheet in our Electronic Health Record (EHR) based on the Epilepsy Learning Healthcare System (ELHS) Case Report Forms to increase seizure documentation in a standardized way. Two epileptologists tested this flowsheet tool in their epilepsy clinics between February 2022 and July 2022. Data were collected weekly and compared with documentation from other epileptologists within the same group.

Results

Epileptologists at our center believed they documented seizure frequency for 84%-87% of clinic visits, which aligned with baseline data collection, showing they recorded seizure frequency for 83% of clinic visits. Epileptologists believed they documented ILAE classification for 47%-52% of clinic visits, and baseline data showed this was documented in 33% of clinic visits. They also reported documenting the date of the last seizure for 52%-63% of clinic visits, but this occurred in only 35% of clinic visits. After implementing the new flowsheet, documentation increased to nearly 100% for all fields being completed by the providers who tested the flowsheet.

Discussion

We demonstrated that by implementing an easy-to-use standardized EHR documentation tool, our documentation of critical metrics, as defined by the ELHS, improved dramatically. This shows that simple and practical interventions can substantially improve clinically meaningful documentation.

Later onset focal epilepsy with roots in childhood: Evidence from early learning difficulty and brain volumes in the Human Epilepsy Project

OBJECTIVE

Visual assessment of magnetic resonance imaging (MRI) from the Human Epilepsy Project 1 (HEP1) found 18% of participants had atrophic brain changes relative to age without known etiology. Here, we identify the underlying factors related to brain volume differences in people with focal epilepsy enrolled in HEP1.

METHODS

Enrollment data for participants with complete records and brain MRIs were analyzed, including 391 participants aged 12-60 years. HEP1 excluded developmental or cognitive delay with intelligence quotient <70, and participants reported any formal learning disability diagnoses, repeated grades, and remediation. Prediagnostic seizures were quantified by semiology, frequency, and duration. T1-weighted brain MRIs were analyzed using Sequence Adaptive Multimodal Segmentation (FreeSurfer v7.2), from which a brain tissue volume to intracranial volume ratio was derived and compared to clinically relevant participant characteristics.

RESULTS

Brain tissue volume changes observable on visual analyses were quantified, and a brain tissue volume to intracranial volume ratio was derived to compare with clinically relevant variables. Learning difficulties were associated with decreased brain tissue volume to intracranial volume, with a ratio reduction of .005 for each learning difficulty reported (95% confidence interval [CI] = -.007 to -.002, p = .0003). Each 10-year increase in age at MRI was associated with a ratio reduction of .006 (95% CI = -.007 to -.005, p < .0001). For male participants, the ratio was .011 less than for female participants (95% CI = -.014 to -.007, p < .0001). There were no effects from seizures, employment, education, seizure semiology, or temporal lobe electroencephalographic abnormalities.

SIGNIFICANCE

This study shows lower brain tissue volume to intracranial volume in people with newly treated focal epilepsy and learning difficulties, suggesting developmental factors are an important marker of brain pathology related to neuroanatomical changes in focal epilepsy. Like the general population, there were also independent associations between brain volume, age, and sex in the study population.

Impact of Seizures While Driving Prior to Diagnosis in People With Focal Epilepsy: Motor Vehicle Accidents and Time to Diagnosis

OBJECTIVES

To identify the type, frequency, and consequences of seizures while driving (SzWD) in people with epilepsy before diagnosis.

METHODS

We performed a retrospective cohort study using the Human Epilepsy Project (HEP) to identify prediagnostic SzWD. Clinical descriptions from seizure diaries and medical records were used to classify seizure types and frequencies, time to diagnosis, and SzWD outcomes. Data were modeled using multiple logistic regression to assess for factors independently associated with SzWD.

RESULTS

32 prediagnostic SzWD were reported among 23/447 (5.1%) participants. Of them, 7 (30.4%) had more than 1. Six participants (26.1%) experienced SzWD as their first lifetime seizure. Most SzWD were focal with impaired awareness (n = 27, 84.4%). Of participants who had motor vehicle accidents (MVAs), 6 (42.9%) had no recollection. SzWD led to hospitalization in 11 people. The median time from first seizure to first SzWD was 304 days (IQR = 0-4,056 days). The median time between first SzWD and diagnosis was 64 days (IQR = 10-176.5 days). Employment was associated with a 3.95-fold increased risk of SzWD (95% CI 1.2-13.2, p = 0.03), and nonmotor seizures were associated with a 4.79-fold increased risk (95% CI 1.3-17.6, p = 0.02).

DISCUSSION

This study identifies the consequences of seizure-related MVAs and hospitalizations people experience before epilepsy diagnosis. This highlights the need for further research aimed at improving seizure awareness and improving time to diagnosis.

Treatment gaps in epilepsy

Over 50 million people around the world have epilepsy, and yet, epilepsy recognition and access to care are ongoing issues. Nearly 80% of people with epilepsy live in low-and middle-income countries and face the greatest barriers to quality care. However, there are substantial disparities in care within different communities in high-income countries as well. Across the world, under-recognition of seizures continues to be an issue, leading to diagnostic and treatment delays. This stems from issues surrounding stigma, public education, basic access to care, as well as healthcare worker education. In different regions, people may face language barriers, economic barriers, and technological barriers to timely diagnosis and treatment. Even once diagnosed, people with epilepsy often face gaps in optimal seizure control with the use of antiseizure medications. Additionally, nearly one-third of people with epilepsy may be candidates for epilepsy surgery, and many either do not have access to surgical centers or are not referred for surgical evaluation. Even those who do often experience delays in care. The purpose of this review is to highlight barriers to care for people with epilepsy, including issues surrounding seizure recognition, diagnosis of epilepsy, and the initiation and optimization of treatment.

Standardization of seizure response times and data collection in an epilepsy monitoring unit

OBJECTIVE

We sought to improve seizure response times in the epilepsy monitoring unit, improve the accuracy and reliability of seizure response time data collection, and develop a standardized and automated approach for seizure response data collection in the EMU.

METHODS

We used Quality Improvement (QI) methodology to understand the EMU workflow involved in responding to seizures (a process map); to create a theory of change that stated the desired aim, potential drivers/barriers and interventions (i.e., key driver diagram) and perform iterative interventions to address some of the drivers plan-do-study-act (PDSA) cycles. We performed three PDSA cycles with a focus on improving the seizure alert system in our EMU. Adjustments were made to the methodology as it became clear that this was a systems issue, and our project would need to focus on improving the system rather than iteratively improving a functioning (stable) system.

RESULTS

Over a 6-month period, 252 seizure response times were recorded and analyzed. We performed 3 interventions. The first was initiating twice monthly meetings with nursing and EEG techs to discuss the project and provide feedback on response times. The second was the implementation of a new Hill-Rom seizure alert system to reduce alert times and automate data tracking. The third was implementing a new alert deactivation system to reduce variability in the data. Following these 3 interventions, variation, and data collection methods were improved while also maintaining improvements in seizure response times.

SIGNIFICANCE

We identified and implemented an alert system in our EMU which led to more efficient and accurate data collection while maintaining improved response times that resulted from the first intervention. This lays the groundwork for future QI initiatives and has created a framework for standardizing seizure response time recording and data collection that can be replicated at other centers with similar infrastructure, personnel and workflows.

Evaluation and Treatment of Seizures and Epilepsy During the COVID-19 Pandemic

Purpose of Review

Seizures, including status epilepticus, have been reported in association with acute COVID-19 infection. People with epilepsy (PWE) have suffered from seizure exacerbations during the pandemic. This article reviews the data for clinical and electrographic seizures associated with COVID-19, technical EEG considerations for reducing risk of transmission, and factors contributing to seizure exacerbations in PWE as well as strategies to address this issue.

Recent Findings

An increasing number of studies of larger cohorts, accounting for a variety of variables and often utilizing EEG with standardized terminology, are assessing the prevalence of seizures in hospitalized patients with acute COVID-19 infections, and gaining insight into the prevalence of seizures and their effect on outcomes. Additionally, recent studies are evaluating the effect of the pandemic on PWE, barriers faced, and the usefulness of telehealth.

Summary

Although there is still much to learn regarding COVID-19, current studies help in assessing the risk of seizures, guiding EEG utilization, and optimizing the use of telehealth during the pandemic.

The language of seizure identification: A qualitative investigation

OBJECTIVE

Clinical history taking is often the most important factor in seizure recognition and the diagnosis of epilepsy. Apart from subspecialist evaluation, patients frequently present for initial evaluation of seizures in emergency departments, urgent care clinics, and primary care clinics. We utilized qualitative methods to assess the current approaches and language used by both subspecialist and non-specialist physicians when interviewing adult patients with suspected seizures to create a clinical tool to aid in seizure diagnosis.

METHODS

We carried out semi- structured interviews with 10 physicians spanning a range of specialties, practice locations, and clinical experience. This included epilepsy specialists and non-specialists in fields where evaluation of new-onset seizures is common: emergency medicine, internal medicine, and family medicine. Thematic analysis was used to develop a "Seizure Identifier" questionnaire, which was subsequently reviewed by five independent experts for content and face validity.

RESULTS

Our analysis revealed that across specialties and practice settings, physicians have a structured approach in evaluating patients who present with suspected seizures. Five key characteristics important for identifying seizures emerged across interviews: sudden-onset unprovoked symptoms, short-lasting symptoms, strange or difficult-to-describe symptoms, highly stereotyped symptoms, and postictal symptoms. After independent review, these were translated into an eight-question "Seizure Identifier" tool.

SIGNIFICANCE

This study highlights important concepts for clinical practice regarding seizure identification. Using themes from our analysis, we were able to create a tool that may aid non-specialists in the approach to history taking for adult patients who present with suspected seizures and may help improve time to subspecialist evaluation. Importantly, this tool can be tested in future research for improving seizure recognition and improving timely epilepsy diagnosis.

Prospective multisite cohort study of patient-reported outcomes in adults with new-onset seizures

Objective

New‐onset seizures affect up to 10% of people over their lifetime, however, their health economic impact has not been well‐studied. This prospective multicenter study will collect patient‐reported outcome measures (PROMs) from adults with new‐onset seizures seen in six Seizure Clinics across Melbourne, Australia and The University of Colorado, USA.

Methods

Approximately 450 eligible patients will be enrolled in the study at or following their initial attendance to Seizure Clinics at the study hospitals. Inclusion criteria for the study group are those with new‐onset acute symptomatic seizures, new‐onset unprovoked seizures, and new‐onset epilepsy. Inclusion criteria for the three comparator groups are those with noncardiac syncope, those with psychogenic nonepileptic seizures, as well as published PROMs data from the Australian general population. Exclusion criteria are those aged less than 18 years, those with a preexisting epilepsy diagnosis, and those with intellectual disabilities or other impairments which would preclude them from comprehending and completing the questionnaires. Patients will complete eight online questionnaires regarding the effect that their seizures (or seizure mimics) have had on various aspects of their life. These questionnaires will be readministered at 6 and 12 months. Patients with new‐diagnosis epilepsy will also be asked to share the reasons why they have accepted or declined antiseizure medications.

Analysis

Primary outcome measures will be quality of life, work productivity, informal care needs, and mood, at baseline compared to 6 and 12 months later for those with new‐onset seizures and comparing these outcomes to those in the three comparator groups. Secondary outcomes include mapping of QoLIE‐31 to the EQ‐5D‐5L in epilepsy, modelling indirect costs of new‐onset seizures, and exploring why patients may or may not wish to take antiseizure medications.

Significance

These data will form an evidence‐base for future studies that examine the effectiveness of various healthcare interventions for new‐onset seizure patients.

Ethics and dissemination

This study is approved by the Alfred Health Human Research Ethics Committee (SERP: 52 538, Alfred HREC: 307/19), the Austin Health Human Research Ethics Committee (HREC/59148/Austin‐2019), and the Colorado Multiple Institutional Review Board (COMIRB) (COMIRB #20‐3028).

ANZCTR trial registration number

ACTRN12621000908831.

Diagnostic Delay in Epilepsy: the Scope of the Problem

PURPOSE OF REVIEW

Diagnostic delay is an increasingly recognized issue in epilepsy. At the same time, there is a clear disparity between public awareness of epilepsy and that of other public health issues. A contributing factor for this seems to be a lack of studies testing interventions designed to improve seizure recognition. In this review, we summarize the main findings from recent studies investigating diagnostic delay in epilepsy, highlighting causes, consequences, and potential interventions in future research that may improve quality of care in this population.

RECENT FINDINGS

Building on prior evidence, diagnostic delay in patients with new-onset focal epilepsy has been identified as an important problem for patients with epilepsy. Such delay in diagnosis can lead to delayed treatment and potentially preventable morbidity and mortality including motor vehicle accidents. Nonmotor seizure semiology appears to be a major contributor for delay; such seizures are largely unrecognized when patients present to emergency departments for care. Improving recognition and diagnosis of recurrent nonmotor seizures in emergency departments represents a significant opportunity for improving time to diagnosis, particularly when patients present following a first lifetime motor seizure and meet diagnostic criteria for epilepsy. Diagnostic delay in epilepsy is a significant public health issue and recent studies have highlighted potential areas for intervention.

The Impact of Clinical Seizure Characteristics on Recognition and Treatment of New-onset Focal Epilepsy in Emergency Departments

OBJECTIVE

Many people with new-onset focal epilepsy initially seek evaluation in emergency departments (EDs), and treatment decisions in EDs can influence likelihood of seizure recurrence. Using data collected for the Human Epilepsy Project (HEP), we assessed the effect of clinical seizure characteristics on ED clinical management.

METHODS

There were 447 participants with new-onset focal epilepsy seen within 4 months of treatment initiation who were eligible and enrolled in HEP. Seizure calendars and medical records were collected. Based on clinical descriptions, seizures were categorized by semiology according to International League Against Epilepsy (ILAE) classifications as either focal nonmotor or focal motor seizures.

RESULTS

Overall, 279 of 447(62%) of participants had presented to an ED prior to or at time of epilepsy diagnosis. A total of 132 of 246 (53%) with initial nonmotor seizures presented to an ED. Of these, eight (6%) presented with a first-lifetime nonmotor seizure. The other 124 (94%) presented after multiple seizures: seven (5%) with multiple nonmotor seizures and 117 (89%) with a first-lifetime motor seizure after having prior nonmotor seizures. A total of 147 of 201 (73%) participants with initial motor seizures presented to an ED. Of these, 134 (92%) presented with a first-lifetime motor seizure and 13 (9%) with multiple motor seizures. There was no difference in the likelihood of antiseizure medication initiation between participants who had multiple prior nonmotor seizures followed by a motor seizure (thereby fulfilling the criterion for an epilepsy diagnosis) versus those presenting with a single lifetime motor seizure (39% vs. 43%). There was no difference in recognition of seizures as the presenting complaint (85% vs. 87%) or whether the participant was admitted or referred to a neurologist (87% vs. 79%).

CONCLUSIONS

This study contributes to evidence of underrecognition of nonmotor focal seizure semiologies in ED settings, which can support large-scale interventions aimed at improving recognition, specialist consultation, and treatment in ED settings.

MRI-negative PET-negative epilepsy long-term surgical outcomes: A single-institution retrospective review

PURPOSE

Surgical planning for people with drug resistant non-lesional focal epilepsy can be challenging. Prior studies focus on cases that are only MRI-negative or MRI-negative with PET-positive imaging, but little is known about outcomes in patients with non-lesional findings on both MRI and PET imaging. In this study, we investigate 5-year surgical outcomes in patients who underwent epilepsy surgery for drug resistant MRI/PET-negative focal epilepsy.

METHODS

We collected clinical and testing data on 131 consecutive patients with drug resistant non-lesional epilepsy who were presented at a multidisciplinary epilepsy surgery conference at the New York University Comprehensive Epilepsy Center between 2010 and 2014, and identified those who underwent epilepsy surgery in order to review 5-year surgical outcomes.

RESULTS

There were 103 with non-lesional MRI studies, and of these, 22 had corresponding non-lesional PET imaging. 14 MRI/PET-negative patients pursued a surgical treatment option and 9 underwent resections after intracranial EEG. At 5 years, 77.8 % of patients had favorable (ILAE class 1 and 2) outcomes. Most (77.8 %) had focal cortical dysplasia type Ia (FCDIa) on pathology.

CONCLUSION

These findings suggest that with careful planning and patient selection, surgery for patients with drug resistant MRI/PET-negative focal epilepsy can be successful.

Continuous EEG findings in patients with COVID-19 infection admitted to a New York academic hospital system

OBJECTIVE

There is evidence for central nervous system complications of coronavirus disease 2019 (COVID-19) infection, including encephalopathy. Encephalopathy caused by or arising from seizures, especially nonconvulsive seizures (NCS), often requires electroencephalography (EEG) monitoring for diagnosis. The prevalence of seizures and other EEG abnormalities among COVID-19-infected patients is unknown.

METHODS

Medical records and EEG studies of patients hospitalized with confirmed COVID-19 infections over a 2-month period at a single US academic health system (four hospitals) were reviewed to describe the distribution of EEG findings including epileptiform abnormalities (seizures, periodic discharges, or nonperiodic epileptiform discharges). Factors including demographics, remote and acute brain injury, prior history of epilepsy, preceding seizures, critical illness severity scores, and interleukin 6 (IL-6) levels were compared to EEG findings to identify predictors of epileptiform EEG abnormalities.

RESULTS

Of 111 patients monitored, most were male (71%), middle-aged or older (median age 64 years), admitted to an intensive care unit (ICU; 77%), and comatose (70%). Excluding 11 patients monitored after cardiac arrest, the most frequent EEG finding was moderate generalized slowing (57%), but epileptiform findings were observed in 30% and seizures in 7% (4% with NCS). Three patients with EEG seizures did not have epilepsy or evidence of acute or remote brain injury, although all had clinical seizures prior to EEG. Only having epilepsy (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.4-21) or seizure(s) prior to EEG (OR 4.8, 95% CI 1.7-13) was independently associated with epileptiform EEG findings.

SIGNIFICANCE

Our study supports growing evidence that COVID-19 can affect the central nervous system, although seizures are unlikely a common cause of encephalopathy. Seizures and epileptiform activity on EEG occurred infrequently, and having a history of epilepsy or seizure(s) prior to EEG testing was predictive of epileptiform findings. This has important implications for triaging EEG testing in this population.

Intensification of UV-C tertiary treatment: Disinfection and removal of micropollutants by sulfate radical based Advanced Oxidation Processes

This study explores the enhancement of UV-C tertiary treatment by sulfate radical based Advanced Oxidation Processes (SR-AOPs), including photolytic activation of peroxymonosulfate (PMS) and persulfate (PS) and their photocatalytic activation using Fe(II). Their efficiency was assessed both for the inactivation of microorganisms and the removal or micropollutants (MPs) in real wastewater treatment plant effluents. Under the studied experimental range (UV-C dose 5.7-57 J/L; UV-C contact time 3 to 28 s), the photolysis of PMS and PS (0.01 mM) increased up to 25% the bacterial removal regarding to UV-C system. The photolytic activation of PMS led to the total inactivation of bacteria (≈ 5.70 log) with the highest UV-C dose (57 J/L). However, these conditions were insufficient to remove the MPs, being required oxidant's dosages of 5 mM to remove above 90% of carbamazepine, diclofenac, atenolol and triclosan. The best efficiencies were achieved by the combination of PMS or PS with Fe(II), leading to the total removal of the MPs using a low UV-C dosage (19 J/L), UV-C contact time (9 s) and reagent's dosages (0.5 mM). Finally, high mineralization was reached (>50%) with photocatalytic activation of PMS and PS even with low reagent's dosages.

Mice with altered brain lipoprotein metabolism display maladaptive responses to environmental challenges that may predispose to weight gain

BACKGROUND

Three-month-old neuron-specific lipoprotein lipase (LPL)-depleted mice (NEXLP(-/-)) mice are preobese and have normal body weight before developing obesity by 4.5 months. This series of experiments investigated responses to novel environment stimuli and acute sleep deprivation in preobese NEXLPL(-/-)) mice to test the hypothesis that neuron-specific LPL deletion alters normal adaptive metabolic responses to environmental challenges.

METHODS

Three-month-old, age- and weight-matched, male NEXLPL(-/-)) (n=10) and wild-type (WT) (n=10) mice were housed in individual metabolic chambers with a 12-hr dark cycle. Food and water intake, locomotor activity, and calorimetry data were recorded in 12-min intervals. Novel environmental responses were elicited by first-time introduction to chambers at dark onset, followed by acclimation, baseline recording, and 6-hr of sleep deprivation on subsequent experimental days.

RESULTS

NEXLPL(-/-)) mice displayed a 1.5-fold greater increase in activity in response to a novel environment than seen in WT controls (P=0.0308), and a two-fold greater increase in food intake following acute sleep deprivation (P=0.0117). NEXLPL(-/-)) mice averaged a 27% higher metabolic rate than WT mice throughout the experiments (P<0.0001). Body weight, composition, and temperature did not differ between murine groups throughout the experiments. Levels of free fatty acid, insulin, glucose, and triglycerides were similar between groups at the terminus.

CONCLUSIONS

A deficiency in neuronal LPL signaling disrupts normal responses to novel environmental exposure and acute sleep deprivation, a maladaptive response that may contribute to weight gain in genetically predisposed mice, and perhaps humans.

The effects of C75, an inhibitor of fatty acid synthase, on sleep and metabolism in mice

Sleep is greatly affected by changes in metabolic state. A possible mechanism where energy-sensing and sleep-regulatory functions overlap is related to lipid metabolism. Fatty acid synthase (FAS) plays a central role in lipid metabolism as a key enzyme in the formation of long-chain fatty acids. We studied the effects of systemic administration of C75, an inhibitor of FAS, on sleep, behavioral activity and metabolic parameters in mice. Since the effects of C75 on feeding and metabolism are the opposite of ghrelin's and C75 suppresses ghrelin production, we also tested the role of ghrelin signaling in the actions of C75 by using ghrelin receptor knockout (KO) mice. After a transient increase in wakefulness, C75 elicited dose-dependent and long lasting inhibition of REMS, motor activity and feeding. Simultaneously, C75 significantly attenuated slow-wave activity of the electroencephalogram. Energy expenditure, body temperature and respiratory exchange ratio were suppressed. The diurnal rhythm of feeding was completely abolished by C75. There was significant correlation between the anorectic effects, the decrease in motor activity and the diminished energy expenditure after C75 injection. We found no significant difference between wild-type and ghrelin receptor KO mice in their sleep and metabolic responses to C75. The effects of C75 resemble to what was previously reported in association with visceral illness. Our findings suggest that sleep and metabolic effects of C75 in mice are independent of the ghrelin system and may be due to its aversive actions in mice.

Impaired wake-promoting mechanisms in ghrelin receptor-deficient mice

Ghrelin receptors are expressed by key components of the arousal system. Exogenous ghrelin induces behavioral activation, promotes wakefulness and stimulates eating. We hypothesized that ghrelin-sensitive mechanisms play a role in the arousal system. To test this, we investigated the responsiveness of ghrelin receptor knockout (KO) mice to two natural wake-promoting stimuli. Additionally, we assessed the integrity of their homeostatic sleep-promoting system using sleep deprivation. There was no significant difference in the spontaneous sleep-wake activity between ghrelin receptor KO and wild-type (WT) mice. WT mice mounted robust arousal responses to a novel environment and food deprivation. Wakefulness increased for 6 h after cage change accompanied by increases in body temperature and locomotor activity. Ghrelin receptor KO mice completely lacked the wake and body temperature responses to new environment. When subjected to 48 h food deprivation, WT mice showed marked increases in their waking time during the dark periods of both days. Ghrelin receptor KO mice failed to mount an arousal response on the first night and wake increases were attenuated on the second day. The responsiveness to sleep deprivation did not differ between the two genotypes. These results indicate that the ghrelin-receptive mechanisms play an essential role in the function of the arousal system but not in homeostatic sleep-promoting mechanisms.

Initial steps in the pathway for bacterial degradation of two tetrameric lignin model compounds

We investigated the metabolic route by which a lignin tetramer-degrading mixed bacterial culture degraded two tetrameric lignin model compounds containing beta-O-4 and 5-5 biphenyl structures. The alpha-hydroxyl groups in the propane chain of both phenolic and nonphenolic tetramers were first oxidized symmetrically in two successive steps to give monoketones and diketones. These ketone metabolites were decomposed through C(alpha)(=O)-C(beta) cleavage, forming trimeric carboxyl acids which were further metabolized through another C(alpha)(=O)-C(beta) cleavage. Dehydrodiveratric acid, which resulted from the cleavage of the carbon bonds of the nonphenol tetramer, was demethylated twice. Four metabolites of the phenolic tetramer were purified and identified. All of these were stable compounds in sterile mineral medium, but were readily degraded by lignin tetramer-degrading bacteria along the same pathway as the phenol tetramer. No monoaromatic metabolites accumulated. All metabolites were identified by mass and proton magnetic resonance spectrometry. The metabolic route by which the mixed bacterial culture degraded tetrameric lignin model compounds was different from the route of the main ligninase-catalyzed C(alpha)-C(beta) cleavage by Phanerochaete chrysosporium.

EOX and organochlorine compounds in fish and ringed seal samples from Lake Ladoga, Russia

Information about the pollution of Lake Ladoga, the largest lake in Europe, has been controversial. Various effluents and drainage waters affect the quality of the lake water. Wastewaters have caused eutrophication of parts of Lake Ladoga, but concentrations of persistent organic pollutants in the lake's food webs are poorly understood. In this study, concentrations of some organochlorine compounds, chlorophenols (CPs), and extractable organic halogen (EOX) were determined in smelt (Osmerus eperlanus), vendace (Coregonus albula), pikeperch (Lucioperca lucioperca), whitefish (Coregonus lavaretus), and the Ladoga seal (Phoca hispida ladogensis) from the northern part of the lake. The concentrations of organochlorine compounds in fish were low. Concentrations were between 0.07 and 0.15, 0.65 and 1.0, and 0.29 and 0.48 mg/kg lipids for hexachlorobenzene, total polychlorinated biphenyl (PCB) and p,p'-DDE, respectively. The results indicated biomagnification from smelt and vendace to pikeperch and ringed seal. In ringed seals, concentrations of PCB and DDT were 12 and 29 times higher than in fish used by ringed seals as major food sources.

Body residues and responses of the midge chironomus riparius to sediment-associated 2,4,5-trichlorophenol in subchronic and chronic exposures

Subchronic and chronic toxicity of sediment-associated 2,4, 5-trichlorophenol to the midge Chironomus riparius was determined by conducting a 10-day growth and a 50-day emergence tests with spiked lake sediment (nominal initial TCP concentrations were 25, 51, 101, 203, 304 and 405 &mgr;mol kg-1 dry weight in the growth test and 25, 76, 152 and 304 &mgr;mol kg-1 dry weight the emergence test). In addition, we measured the residue of chlorophenol in larval tissue and made an attempt to relate it with the observed adverse biological responses. The larvae were exposed individually to avoid density-dependent effects of mortality on food ration and growth of the surviving larvae. In the growth test, mortality was low at sediment concentrations </=193 &mgr;mol TCP kg-1, but it increased sharply at the higher concentrations being 37 and 94% at 334 and 441 &mgr;mol kg-1 DW, respectively. The effect of sediment TCP concentration on larval mortality was highly significant (10-day LC50 337 &mgr;mol TCP kg-1 dry sediment) in the growth test. In the emergence test, however, mortality was low (3-13%) at all concentrations. TCP did not affect larval growth at the concentrations used. The concentration of TCP in the whole larvae after the 10-day exposure was proportional to sediment concentration, being at highest 160 &mgr;mol kg-1 fresh weight. When the average body residues of TCP were below 80 &mgr;mol kg-1, mortality was low, but it increased when the body residue approached 100 &mgr;mol kg-1. After the 10-day exposure, the body residue, at which 50% of the larvae survived (CBR50) was 113 &mgr;mol g-1. TCP exposure accelerated larval development and the midges exposed to 171 and 324 &mgr;mol TCP kg-1 emerged earlier than those in the other concentrations or in the control sediment. In natural environments, sediment-associated chlorophenolics are probably not a major environmental problem to benthic fauna because concentrations similar to that which we observed to cause adverse effects to C. riparius (>60 mg kg-1 dry sediment) are rare.http://link.springer-ny. com/link/service/journals/00244/bibs/37n1p42.html

Characterization of Lake Ladoga sediments. I. Toxicity to Chironomus riparius and Daphnia magna

Toxicity of surficial sediment of Lake Ladoga, Russia, was studied using bioassays with a midge, Chironomus riparius and Daphnia magna. Many Lake Ladoga sediments caused high mortality of midge larvae in 10-d growth and 40-d emergence tests. In most sediments the biomass production of chironomids was also lowered. However, no statistically significant effect on timing of emergence was observed. Sediment elutriate or pore water tests did not exhibit toxicity to Daphnia magna. The adverse effects observed in midge bioassays indicate the presence of toxic chemicals. It cannot be excluded, however, that the variable sediment physico-chemical characteristics could also have had some effect.

Physiological toxicity of low-chlorine bleached pulp and paper mill effluent on whitefish (Coregonus lavaretus L. s.l.): a laboratory exposure simulating lake pollution

In order to validate previous field observations by the authors on whitefish, Coregonus lavaretus L. s.l., a 30-day laboratory experiment with concentrations (0, 1.3, 2.3, 3.5, and 7 vol%) of bleached kraft pulp and paper mill effluent (BKME) simulating those occurring in a polluted lake was conducted. Chlorine dioxide had almost entirely replaced chlorine gas in the bleaching of pulp. As a consequence, the concentrations of adsorbable organic halogens and chlorinated phenolics (CPs) in BKME were significantly lowered compared to earlier studies. This reduction was also seen in the concentrations of CPs in the bile and CPs and extractable organic halogens in the intestinal lipids: the concentrations were low and did not depend on the dilution of BKME. In contrast, the resin acid content of bile decreased with decreasing BKME concentration. The growth of fish was speeded up in all BKME concentrations. However, at the highest BKME concentration (7 vol%) the increase was lowest. The induction of hepatic ethoxyresorufin O-deethylase (EROD) activity revealed strong dose-response relationship with BKME. At 3.5 vol% BKME (corresponding to a distance of 3.3 km from the mill sewer in the field) the EROD activity increased 12-fold. There was a tendency for lower activity of uridinediphosphate glucuronosyltransferase in the liver, but the decrease (34%; P < 0.05) was statistically significant only at 7 vol% BKME. The activity of liver glutathione S-transferase remained unchanged. All dilutions of BKME significantly depressed the concentrations of plasma immunoglobulin M (IgM). Erythrocytic concentrations of nucleotide triphosphates decreased and of sodium increased as the BKME concentration increased. Also some other blood parameters (hematocrit, hemoglobin, plasma glucose, and aspartate aminotransferase) were changed in all BKME exposures, although without obvious dependence on effluent concentration. In conclusion, there was a good agreement between field studies and laboratory experiments using BKME concentrations occurring in the field, confirming close or similar causes for responsive toxicity endpoints.

Benzodiazepines, but not antidepressants or neuroleptics, induce dose-dependent development of tolerance to lorazepam in psychiatric patients

Psychomotor effects of oral lorazepam 3 mg were studied in psychiatric patients stratified into four groups: 1) a group of six patients with no previous use of psychotrophic drugs (NoD), 2) a group of 12 patients treated with antidepressants and/or neuroleptics (PsyD), 3) a group of 10 patients treated with low doses of benzodiazepines (BZs) (lowBZ), and 4) a group of nine patients treated with high doses of BZs (high BZ). Similar objective psychomotor tests and subjective assessments were administered under single-blind conditions to all treatment groups at baseline, after intake of placebo, and after intake of 3 mg lorazepam. Both lorazepam (CGC) and total BZs (bioassay) in serum were assayed. The results demonstrate that treatment with BZs induce dose-dependent development of tolerance to psychomotor effects of lorazepam. Antidepressants and neuroleptics failed to induce cross-tolerance to lorazepam. The rise in serum lorazepam concentrations after lorazepam intake was similar (about 28 micrograms/l) in all treatment groups, suggesting a functional, not dispositional, tolerance. However, the initial learning effect in psychomotor performance was poorer among BZ users than among others.

Interaction of diazepam or lorazepam with alcohol. Psychomotor effects and bioassayed serum levels after single and repeated doses

Nine healthy volunteers in a double-blind, cross-over trial received diazepam (DZ) 10 mg, lorazepam (LZ) 2.5 mg, or placebo (P). Serum benzodiazepine (BZ) was bioassayed (radioreceptor method) and psychomotor tests were carried out on Day 1 (before and 1 h after the first dose) and on Day 4 (before and after the fifth dose). In each session alcohol 1 g/kg was administered 1.5 h after drug intake and the measurements were repeated twice. Serum BZ concentrations, expressed as DZ equivalents (microgram/l), ranged from 390 to 440 and from 990 to 1240 measured 2 h 45 min after the first doses of DZ and LZ, respectively. On Day 1 BZ alone impaired psychomotor skills. LZ affected performance more in objective tests, but DZ was subjectively rated as causing more drowsiness. After the intake of alcohol, all groups showed impairment in various tests. The rank order was LZ + alcohol greater than DZ + alcohol greater than P + alcohol. Residual BZ activity on Day 4, measured 18 h after the fourth dose, averaged 290 and 450 micrograms/l after DZ and LZ, respectively. At the same time slight residual exophoria was found after both BZs. Tolerance to BZs on Day 4 was unambiguous only when drug effects were related to the bioassayed serum levels. The combined action of BZs and alcohol was similar on Days 1 and 4. However, a tendency to an increased drug-alcohol interaction during advanced treatment with DZ was seen in the body sway test.(ABSTRACT TRUNCATED AT 250 WORDS)