To evaluate the risks of continuously administered IV anesthetic drugs (IVADs) on the outcome of adult patients with status epilepticus (SE).All intensive care unit patients with SE from 2005 to 2011 at a tertiary academic medical care center were included. Relative risks were calculated for the primary outcome measures of seizure control, Glasgow Outcome Scale score at discharge, and death. Poisson regression models were used to control for possible confounders and to assess effect modification.Of 171 patients, 37% were treated with IVADs. Mortality was 18%. Patients with anesthetic drugs had more infections during SE (43% vs 11%; p < 0.0001) and a 2.9-fold relative risk for death (2.88; 95% confidence interval 1.45-5.73), independent of possible confounders (i.e., duration and severity of SE, nonanesthetic third-line antiepileptic drugs, and critical medical conditions) and without significant effect modification by different grades of SE severity and etiologies. As IVADs were used after first- and second-line drugs failed, there was a correlation between treatment-refractory SE and the use of IVADs, leading to insignificant results regarding the risk of IVADs and outcome after additional adjustment for refractory SE.Our findings heighten awareness regarding adverse effects of IVADs. Randomized controlled trials are needed to further clarify the association of IVADs with outcome in patients with SE.This study provides Class III evidence that patients with SE receiving IVADs have a higher proportion of infection and an increased risk of death as compared to patients not receiving IVADs.
Abstract Introduction The Glasgow Coma Scale (GCS) is the most widely used scoring system for comatose patients in intensive care. Limitations of the GCS include the impossibility to assess the verbal score in intubated or aphasic patients, and an inconsistent inter-rater reliability. The FOUR (Full Outline of UnResponsiveness) score, a new coma scale not reliant on verbal response, was recently proposed. The aim of the present study was to compare the inter-rater reliability of the GCS and the FOUR score among unselected patients in general critical care. A further aim was to compare the inter-rater reliability of neurologists with that of intensive care unit (ICU) staff. Methods In this prospective observational study, scoring of GCS and FOUR score was performed by neurologists and ICU staff on 267 consecutive patients admitted to intensive care. Results In a total of 437 pair wise ratings the exact inter-rater agreement for the GCS was 71%, and for the FOUR score 82% ( P = 0.0016); the inter-rater agreement within a range of ± 1 score point for the GCS was 90%, and for the FOUR score 92% ( P = ns.). The exact inter-rater agreement among neurologists was superior to that among ICU staff for the FOUR score (87% vs. 79%, P = 0.04) but not for the GCS (73% vs. 73%). Neurologists and ICU staff did not significantly differ in the inter-rater agreement within a range of ± 1 score point for both GCS (88% vs. 93%) and the FOUR score (91% vs. 88%). Conclusions The FOUR score performed better than the GCS for exact inter-rater agreement, but not for the clinically more relevant agreement within the range of ± 1 score point. Though neurologists outperformed ICU staff with regard to exact inter-rater agreement, the inter-rater agreement of ICU staff within the clinically more relevant range of ± 1 score point equalled that of the neurologists. The small advantage in inter-rater reliability of the FOUR score is most likely insufficient to replace the GCS, a score with a long tradition in intensive care.
To assess the risk of first-time seizures in association with exposure to antidepressants in patients with depressive disorders. We conducted a retrospective follow-up study with a nested case-control analysis using data from the U.K.-based Clinical Practice Research Datalink. We estimated incidence rates (IRs) with 95% confidence intervals (CIs) of seizures in depressed patients who used no antidepressant treatment or who used selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), or 'other antidepressants'. To better adjust for potential confounding, we estimated odds ratios (ORs) of antidepressant drug use among cases with seizures and matched controls in a nested case-control analysis. Of 151,005 depressed patients, 619 had an incident seizure during follow-up. IRs per 10,000 person-years were 9.33 (95% CI, 6.19-12.46) in non-users of antidepressants, 12.44 (95% CI, 10.67-14.21) in SSRI users, 15.44 (95% CI, 8.99-21.89) in SNRI users, 8.33 (95% CI, 4.68-11.98) in TCA users, and 5.05 (95% CI, 4.49-5.62) in past users of antidepressants. Across single antidepressants, the highest IR per 10,000 person-years (17.06 [95% CI, 7.41-26.72]) was observed in mirtazapine users. In the case-control analysis we observed the highest risks of seizure in male users of other antidepressants (OR 3.90, 95% CI 1.85-8.26), and in female users of SNRIs (2.70, 95% CI 1.33-5.48) compared with non-use. With the exception of TCAs, antidepressant use in depressed patients was associated with an increased risk of seizures compared to non-use. Risk estimates differed across antidepressants and depended on timing of therapy, dose, and sex.
Abstract Objective The Swiss guidelines for driving with epilepsy require that electroencephalogram (EEG) findings must be compatible with the fitness to drive (FTD) without specifying any criteria. This nationwide survey investigated how Swiss neurologists implement this requirement in clinical practice. Methods An online survey, including 19 EEG examples and statements about the compatibility of the EEG with FTD, was distributed to all members of the Swiss Society of Clinical Neurophysiology and all Swiss neurological clinics with residency programs. Descriptive statistics and Fleiss' Kappa for inter‐rater agreement were performed. Results 102 participants (37% female, 45% <45 years) completed the survey, with 15% primarily working in a specialized epileptology center (EPI), 55% in a hospital setting without epileptological focus (HOS), and 30% in private practice (PP). Most participants of all three groups regarded EEG normal variants as compatible with FTD, while hyperventilation‐induced rhythmic slowing and some pathological patterns (e.g., frontal and temporal intermittent rhythmic delta activity [FIRDA, TIRDA], focal interictal epileptiform discharges [IED], focal seizure) were evaluated more heterogeneously. The EEG inter‐rater agreement for EPI was 0.4; 0.31 for PP; and 0.24 for HOS. No consensus was found for acceptable duration for generalized or focal IEDs. Among all participants, evaluation by an epilepsy center (85%) and reaction‐time testing (67%) were evaluated as the most useful additional examinations. However, reaction‐time testing is rarely or never performed by 58%. Most supported EEG results as part of the FTD assessment and demanded more research (both 82%). Significance Our survey indicates considerable heterogeneity among Swiss neurologists when evaluating the EEG findings for FTD. Inter‐rater agreement in all three groups was fair, with highest agreement among epileptologists. We noted a discrepancy between the usefulness and actual application of reaction‐time testing. More training and research are warranted to achieve rater‐independent consistency for FTD evaluation. Plain Language Summary In Switzerland, neurologists must consider the findings from EEG (brain waves) exams to evaluate driving safety in people with epilepsy. We surveyed Swiss neurologists, asking their opinions on this matter. We found that opinions differ among individual doctors, with the highest agreement among epilepsy specialists. We also found that some additional tests, such as reaction‐time testing, are perceived as useful but are rarely performed. The participating neurologists supported considering EEG results for driving fitness assessments but favored more precise guidelines and research.
Periodic social events may influence the incidence and course of status epilepticus (SE), likely explained by patients' behavioral changes regarding alcohol intake, sleep, and compliance with antiseizure medication. However, data regarding the association between such events and SE are lacking. The aim of this study was to identify and quantify associations between periodic social events and the incidence, etiology, and outcome of SE.Adult patients who were admitted to a tertiary academic medical care center with SE from 2005 to 2015 were included. Associations between periodic social events (including birthday, Christmas, New Year's Eve, carnival, national holiday) and the number and etiologies of SE over time were calculated using linear and Poisson regression. Logistic regression was applied to identify associations between time from social events and outcome.Four hundred nine patients with a median age of 66 years (interquartile range 52-76) were analyzed. The number of total SE events and SE in patients with known epilepsy peaked within 2 weeks following social events and then decreased with each additional day (incidence rate ratio [IRR]per day 0.99, 95% confidence interval [CI] 0.98-0.99; P < .001 and IRRper day 0.99, 95% CI 0.98-0.99; P < .001, respectively) and week (IRRper week 0.94, 95% CI 0.93-0.95; P < .001 and IRRper week 0.94, 95% CI 0.92-0.96; P < .001, respectively). The highest proportion of epilepsy patients not taking antiseizure medication was seen closest to social events and decreased thereafter (IRRper day 0.99, 95% CI 0.98-0.99; P = .003). There was no association between time from social events and outcome.Our findings support the hypothesis that periodic social events in adults may be associated with an increase in SE and should heighten awareness for SE in this context. Clinicians are urged to inform epilepsy patients regarding this association and to instruct them on preventive measures around such events.
Abstract Background One important cause of epileptic treatment failure and emergency department visits is due to non-adherence. Medication adherence is a complex behavior that describes the association between recommended and actual medicine use. Numerous modifiable and unmodifiable factors may affect medication adherence in patients with epilepsy. Other factors, such as pharmacogenetics, need to be considered and may provide opportunities in the future treatment of epilepsy. Method We present the case of a patient with newly diagnosed epilepsy and sub-therapeutic levels for antiseizure medication due to suspected non-adherence. We delineate the main challenges while elucidating the reasons for unmet seizure control, and suggest interventions for adherence management. Results In the case of unmet therapeutic goals, distinguishing non-response, pharmacoresistance, and non-adherence remains a challenge. We suggest first double-checking therapy-related factors (interaction, contra-indication) and adapting them. Then, behavior-related reasons should be elucidated depending on the treatment phase (initiation, implementation, persistence). Improving adherence through modifiable factors targets forgetfulness, medication management, beliefs/concerns, and costs. The intervention should be tailored to the modifiable factors. Pharmacogenetic tests can be used to predict how an individual may respond to a specific pharmacotherapy, but only in specific situations and in combination with other information. Conclusion Non-adherence should be considered as a common cause of epileptic treatment failure. We recommend elucidating the modifiable reasons systematically alongside therapeutic and behavioral factors.
Zusammenfassung Das Elektroenzephalogramm (EEG) ist eine wichtige paraklinische, nichtinvasive, reproduzierbare Untersuchungsmethode bei der diagnostischen Abklärung einer autoimmunen Enzephalitis, und sie dient auch der Therapieüberwachung im Falle von epileptischen Anfällen oder eines Status epilepticus. Bei Letzterem hat die kontinuierliche EEG-Ableitung einen hohen Stellenwert. Die EEG-Veränderungen finden sich v. a. über den temporalen und frontalen Hirnabschnitten; meistens sind sie unspezifisch und können auch bei vielen anderen Hirnerkrankungen beobachtet werden. Einzig der sog. „extreme Delta-Brush“ deutet auf eine Anti-N-Methyl-D-Aspartat(NMDA)-Rezeptor-assoziierte autoimmune Enzephalitis hin; dessen Fehlen bedeutet aber keineswegs den Ausschluss einer solchen Erkrankung. Die im Rahmen der autoimmunen Enzephalitis infolge von Anti-Leucin-reich-Gliom-induziertes Protein‑1(LGI‑1)-Antikörpern ebenfalls fast pathognomonischen nur 1–2 s dauernden faziobrachialen dystonen Anfälle weisen meistens kein EEG-Korrelat auf. Das EEG scheint bei autoimmuner Enzephalitis über eine gewisse Voraussagekraft hinsichtlich des Verlaufs und der Prognose zu verfügen.
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