First name
Nicholas
Middle name
S
Last name
Abend

Title

Visits of concern in child neurology telemedicine.

Year of Publication

2022

Number of Pages

Date Published

05/2022

ISSN Number

1469-8749

Abstract

AIM: To characterize child neurology telemedicine visits flagged as requiring in-person evaluation during the COVID-19 pandemic.

METHOD: We analyzed 7130 audio-video telemedicine visits between March and November 2020. Visits of concern (VOCs) were defined as telemedicine visits where the clinical scenario necessitated in-person follow-up evaluation sooner than if the visit had been conducted in-person.

RESULTS: VOCs occurred in 5% (333/7130) of visits for 292 individuals (148 females, 144 males). Providers noted technical challenges more often in VOCs (40%; 133/333) than visits without concern (non-VOCs) (28%; 1922/6797) (p < 0.05). The median age was younger in VOCs (9 years 3 months, interquartile range [IQR] 2 years 0 months-14 years 3 months) than non-VOCs (11 years 3 months, IQR 5 years 10 months-15 years 10 months) (p < 0.05). Median household income was lower for patients with VOCs ($74 K, IQR $55 K-$97 K) compared to non-VOCs ($80 K, IQR $61 K-$100 K) (p < 0.05). Compared with all other race categories, families who self-identified as Black were more likely to have a VOC (odds ratio 1.53, 95% confidence interval 1.21-2.06). Epilepsy and headache represented the highest percentages of VOCs, while neuromuscular disorders and developmental delay had a higher proportion of VOCs than other neurological disorders.

INTERPRETATION: These findings suggest that telemedicine is an effective platform for most child neurology visits. Younger children and those with neuromuscular disorders or developmental delays are more likely to require in-person evaluation.

DOI

10.1111/dmcn.15256

Alternate Title

Dev Med Child Neurol

PMID

35514061
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Title

Ketamine for Management of Neonatal and Pediatric Refractory Status Epilepticus.

Year of Publication

2022

Number of Pages

Date Published

07/2022

ISSN Number

1526-632X

Abstract

OBJECTIVE: Few data are available regarding the use of anesthetic infusions for refractory status epilepticus (RSE) in children and neonates, and ketamine use is increasing despite limited data. We aimed to describe the impact of ketamine for RSE in children and neonates.

METHODS: Retrospective single-center cohort study of consecutive patients admitted to the intensive care units of a quaternary care children's hospital treated with ketamine infusion for RSE.

RESULTS: Sixty-nine patients were treated with a ketamine infusion for RSE. The median age at onset of RSE was 0.7 years (IQR 0.15-7.2), and the cohort included 13 (19%) neonates. Three patients (4%) had adverse events requiring intervention during or within twelve hours of ketamine administration, including hypertension in 2 patients and delirium in 1 patient. Ketamine infusion was followed by seizure termination in 32 (46%) patients, seizure reduction in 19 (28%) patients, and no change in 18 (26%) patients.

DISCUSSION: Ketamine administration was associated with few adverse events, and seizures often terminated or improved after ketamine administration. Further data are needed comparing first-line and subsequent anesthetic medications for treatment of pediatric and neonatal RSE.

CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence on the therapeutic utility of ketamine for treatment of RSE in children and neonates.

DOI

10.1212/WNL.0000000000200889

Alternate Title

Neurology

PMID

35817569
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Title

Characteristics of Neonates with Cardiopulmonary Disease Who Experience Seizures: A Multicenter Study.

Year of Publication

2022

Number of Pages

63-73

Date Published

2022 03

ISSN Number

1097-6833

Abstract

<p><strong>OBJECTIVE: </strong>To compare key seizure and outcome characteristics between neonates with and without cardiopulmonary disease.</p>

<p><strong>STUDY DESIGN: </strong>The Neonatal Seizure Registry is a multicenter, prospectively acquired cohort of neonates with clinical or electroencephalographic (EEG)-confirmed seizures. Cardiopulmonary disease was defined as congenital heart disease, congenital diaphragmatic hernia, and exposure to extracorporeal membrane oxygenation. We assessed continuous EEG monitoring strategy, seizure characteristics, seizure management, and outcomes for neonates with and without cardiopulmonary disease.</p>

<p><strong>RESULTS: </strong>We evaluated 83 neonates with cardiopulmonary disease and 271 neonates without cardiopulmonary disease. Neonates with cardiopulmonary disease were more likely to have EEG-only seizures (40% vs 21%, P&nbsp;&lt;&nbsp;.001) and experience their first seizure later than those without cardiopulmonary disease (174 vs 21&nbsp;hours of age, P&nbsp;&lt;&nbsp;.001), but they had similar seizure exposure (many-recurrent electrographic seizures 39% vs 43%, P&nbsp;=&nbsp;.27). Phenobarbital was the primary initial antiseizure medication for both groups (90%), and both groups had similarly high rates of incomplete response to initial antiseizure medication administration (66% vs 68%, P&nbsp;=&nbsp;.75). Neonates with cardiopulmonary disease were discharged from the hospital later (hazard ratio 0.34, 95% CI 0.25-0.45, P&nbsp;&lt;&nbsp;.001), although rates of in-hospital mortality were similar between the groups (hazard ratio 1.13, 95% CI 0.66-1.94, P&nbsp;=&nbsp;.64).</p>

<p><strong>CONCLUSION: </strong>Neonates with and without cardiopulmonary disease had a similarly high seizure exposure, but neonates with cardiopulmonary disease were more likely to experience EEG-only seizures and had seizure onset later in the clinical course. Phenobarbital was the most common seizure treatment, but seizures were often refractory to initial antiseizure medication. These data support guidelines recommending continuous EEG in neonates with cardiopulmonary disease and indicate a need for optimized therapeutic strategies.</p>

DOI

10.1016/j.jpeds.2021.10.058

Alternate Title

J Pediatr

PMID

34728234
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Title

Seizure Severity and Treatment Response in Newborn Infants with Seizures Attributed to Intracranial Hemorrhage.

Year of Publication

2022

Number of Pages

121-128.e1

Date Published

2022 Mar

ISSN Number

1097-6833

Abstract

<p><strong>OBJECTIVE: </strong>We sought to characterize intracranial hemorrhage (ICH) as a seizure etiology in infants born term and preterm. For infants born term, we sought to compare seizure severity and treatment response for multisite vs single-site ICH and hypoxic-ischemic encephalopathy (HIE) with vs without ICH.</p>

<p><strong>STUDY DESIGN: </strong>We studied 112 newborn infants with seizures attributed to ICH and 201 infants born at term with seizures attributed to HIE, using a cohort of consecutive infants with clinically diagnosed and/or electrographic seizures prospectively enrolled in the multicenter Neonatal Seizure Registry. We compared seizure severity and treatment response among infants with complicated ICH, defined as multisite vs single-site ICH and HIE with vs without ICH.</p>

<p><strong>RESULTS: </strong>ICH was a more common seizure etiology in infants born preterm vs term (27% vs 10%, P&nbsp;&lt;&nbsp;.001). Most infants had subclinical seizures (74%) and an incomplete response to initial antiseizure medication (ASM) (68%). In infants born term, multisite ICH was associated with more subclinical seizures than single-site ICH (93% vs 66%, P&nbsp;=&nbsp;.05) and an incomplete response to the initial ASM (100% vs 66%, P&nbsp;=&nbsp;.02). Status epilepticus was more common in HIE with ICH vs HIE alone (38% vs 17%, P&nbsp;=&nbsp;.05).</p>

<p><strong>CONCLUSIONS: </strong>Seizure severity was greater and treatment response was lower among infants born term with complicated ICH. These data support the use of continuous video electroencephalogram monitoring to accurately detect seizures and a multistep treatment plan that considers early use of multiple ASMs, particularly with parenchymal and high-grade intraventricular hemorrhage and complicated ICH.</p>

DOI

10.1016/j.jpeds.2021.11.012

Alternate Title

J Pediatr

PMID

34780777
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Title

Benzodiazepine administration patterns before escalation to second-line medications in pediatric refractory convulsive status epilepticus.

Year of Publication

2021

Number of Pages

2766-2777

Date Published

2021 11

ISSN Number

1528-1167

Abstract

<p><strong>OBJECTIVE: </strong>This study was undertaken to evaluate benzodiazepine (BZD) administration patterns before transitioning to non-BZD antiseizure medication (ASM) in pediatric patients with refractory convulsive status epilepticus (rSE).</p>

<p><strong>METHODS: </strong>This retrospective multicenter study in the United States and Canada used prospectively collected observational data from children admitted with rSE between 2011 and 2020. Outcome variables were the number of BZDs given before the first non-BZD ASM, and the number of BZDs administered after 30 and 45&nbsp;min from seizure onset and before escalating to non-BZD ASM.</p>

<p><strong>RESULTS: </strong>We included 293 patients with a median (interquartile range) age of 3.8 (1.3-9.3) years. Thirty-six percent received more than two BZDs before escalating, and the later the treatment initiation was after seizure onset, the less likely patients were to receive multiple BZD doses before transitioning (incidence rate ratio [IRR]&nbsp;=&nbsp;.998, 95% confidence interval [CI] = .997-.999 per minute, p&nbsp;=&nbsp;.01). Patients received BZDs beyond 30 and 45&nbsp;min in 57.3% and 44.0% of cases, respectively. Patients with out-of-hospital seizure onset were more likely to receive more doses of BZDs beyond 30&nbsp;min (IRR&nbsp;=&nbsp;2.43, 95% CI = 1.73-3.46, p&nbsp;&lt;&nbsp;.0001) and beyond 45&nbsp;min (IRR&nbsp;=&nbsp;3.75, 95% CI&nbsp;=&nbsp;2.40-6.03, p&nbsp;&lt;&nbsp;.0001) compared to patients with in-hospital seizure onset. Intermittent SE was a risk factor for more BZDs administered beyond 45&nbsp;min compared to continuous SE (IRR&nbsp;=&nbsp;1.44, 95% CI = 1.01-2.06, p&nbsp;=&nbsp;.04). Forty-seven percent of patients (n&nbsp;=&nbsp;94) with out-of-hospital onset did not receive treatment before hospital arrival. Among patients with out-of-hospital onset who received at least two BZDs before hospital arrival (n&nbsp;=&nbsp;54), 48.1% received additional BZDs at hospital arrival.</p>

<p><strong>SIGNIFICANCE: </strong>Failure to escalate from BZDs to non-BZD ASMs occurs mainly in out-of-hospital rSE onset. Delays in the implementation of medical guidelines may be reduced by initiating treatment before hospital arrival and facilitating a transition to non-BZD ASMs after two BZD doses during handoffs between prehospital and in-hospital settings.</p>

DOI

10.1111/epi.17043

Alternate Title

Epilepsia

PMID

34418087
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Title

Periodic and rhythmic patterns in critically ill children: Incidence, interrater agreement, and seizures.

Year of Publication

2021

Number of Pages

2955-2967

Date Published

2021 12

ISSN Number

1528-1167

Abstract

<p><strong>OBJECTIVES: </strong>We aimed to determine the incidence of periodic and rhythmic patterns (PRP), assess the interrater agreement between electroencephalographers scoring PRP using standardized terminology, and analyze associations between PRP and electrographic seizures (ES) in critically ill children.</p>

<p><strong>METHODS: </strong>This was a prospective observational study of consecutive critically ill children undergoing continuous electroencephalographic monitoring (CEEG). PRP were identified by one electroencephalographer, and then two pediatric electroencephalographers independently scored the first 1-h epoch that contained PRP using standardized terminology. We determined the incidence of PRPs, evaluated interrater agreement between electroencephalographers scoring PRP, and evaluated associations between PRP and ES.</p>

<p><strong>RESULTS: </strong>One thousand three hundred ninety-nine patients underwent CEEG. ES occurred in 345 (25%) subjects. PRP, ES&nbsp;+&nbsp;PRP, and ictal-interictal continuum (IIC) patterns occurred in 142 (10%), 81 (6%), and 93 (7%) subjects, respectively. The most common PRP were generalized periodic discharges (GPD; 43, 30%), lateralized periodic discharges (LPD; 34, 24%), generalized rhythmic delta activity (GRDA; 34, 24%), bilateral independent periodic discharges (BIPD; 14, 10%), and lateralized rhythmic delta activity (LRDA; 11, 8%). ES risk varied by PRP type (p&nbsp;&lt;&nbsp;.01). ES occurrence was associated with GPD (odds ratio [OR] = 6.35, p&nbsp;&lt;&nbsp;.01), LPD (OR = 10.45, p&nbsp;&lt;&nbsp;.01), BIPD (OR = 6.77, p&nbsp;&lt;&nbsp;.01), and LRDA (OR = 6.58, p&nbsp;&lt;&nbsp;.01). Some modifying features increased the risk of ES for each of those PRP. GRDA was not significantly associated with ES (OR = 1.34, p&nbsp;=&nbsp;.44). Each of the IIC patterns was associated with ES (OR = 6.83-8.81, p&nbsp;&lt;&nbsp;.01). ES and PRP occurred within 6&nbsp;h (before or after) in 45 (56%) subjects.</p>

<p><strong>SIGNIFICANCE: </strong>PRP occurred in 10% of critically ill children who underwent CEEG. The most common patterns were GPD, LPD, GRDA, BIPD, and LRDA. The GPD, LPD, BIPD, LRDA, and IIC patterns were associated with ES. GRDA was not associated with ES.</p>

DOI

10.1111/epi.17068

Alternate Title

Epilepsia

PMID

34642942
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Title

Multicenter Study of the Impact of COVID-19 Shelter-In-Place on Tertiary Hospital-based Care for Pediatric Neurologic Disease.

Year of Publication

2022

Number of Pages

218-226

Date Published

2022 Apr

ISSN Number

1941-8744

Abstract

<p><strong>Objective: </strong>To describe changes in hospital-based care for children with neurologic diagnoses during the initial 6&nbsp;weeks following regional Coronavirus 2019 Shelter-in-Place orders.</p>

<p><strong>Methods: </strong>This retrospective cross-sectional study of 7 US and Canadian pediatric tertiary care institutions included emergency and inpatient encounters with a neurologic primary discharge diagnosis code in the initial 6&nbsp;weeks of Shelter-in-Place (COVID-SiP), compared to the same period during the prior 3&nbsp;years (Pre-COVID). Patient demographics, encounter length, and neuroimaging and electroencephalography use were extracted from the medical record.</p>

<p><strong>Results: </strong>27,900 encounters over 4&nbsp;years were included. Compared to Pre-COVID, there was a 54% reduction in encounters during Shelter-in-Place. COVID-SiP patients were younger (median 5&nbsp;years vs 7&nbsp;years). The incidence of encounters for migraine fell by 72%, and encounters for acute diagnoses of status epilepticus, infantile spasms, and traumatic brain injury dropped by 53%, 55%, and 56%, respectively. There was an increase in hospital length of stay, relative utilization of intensive care, and diagnostic testing (long-term electroencephalography, brain MRI, and head CT (all &lt;.01)).</p>

<p><strong>Conclusion: </strong>During the initial 6&nbsp;weeks of SiP, there was a significant decrease in neurologic hospital-based encounters. Those admitted required a high level of care. Hospital-based neurologic services are needed to care for acutely ill patients. Precise factors causing these shifts are unknown and raise concern for changes in care seeking of patients with serious neurologic conditions. Impacts of potentially delayed diagnosis or treatment require further investigation.</p>

DOI

10.1177/19418744211063075

Alternate Title

Neurohospitalist

PMID

35414846
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Title

Super-Refractory Status Epilepticus in Children: A Retrospective Cohort Study.

Year of Publication

2021

Number of Pages

e613-e625

Date Published

2021 12 01

ISSN Number

1529-7535

Abstract

<p><strong>OBJECTIVES: </strong>To characterize the pediatric super-refractory status epilepticus population by describing treatment variability in super-refractory status epilepticus patients and comparing relevant clinical characteristics, including outcomes, between super-refractory status epilepticus, and nonsuper-refractory status epilepticus patients.</p>

<p><strong>DESIGN: </strong>Retrospective cohort study with prospectively collected data between June 2011 and January 2019.</p>

<p><strong>SETTING: </strong>Seventeen academic hospitals in the United States.</p>

<p><strong>PATIENTS: </strong>We included patients 1 month to 21 years old presenting with convulsive refractory status epilepticus. We defined super-refractory status epilepticus as continuous or intermittent seizures lasting greater than or equal to 24 hours following initiation of continuous infusion and divided the cohort into super-refractory status epilepticus and nonsuper-refractory status epilepticus groups.</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>We identified 281 patients (157 males) with a median age of 4.1 years (1.3-9.5 yr), including 31 super-refractory status epilepticus patients. Compared with nonsuper-refractory status epilepticus group, super-refractory status epilepticus patients had delayed initiation of first nonbenzodiazepine-antiseizure medication (149 min [55-491.5 min] vs 62 min [33.3-120.8 min]; p = 0.030) and of continuous infusion (495 min [177.5-1,255 min] vs 150 min [90-318.5 min]; p = 0.003); prolonged seizure duration (120 hr [58-368 hr] vs 3 hr [1.4-5.9 hr]; p &lt; 0.001) and length of ICU stay (17 d [9.5-40 d] vs [1.8-8.8 d]; p &lt; 0.001); more medical complications (18/31 [58.1%] vs 55/250 [22.2%] patients; p &lt; 0.001); lower return to baseline function (7/31 [22.6%] vs 182/250 [73.4%] patients; p &lt; 0.001); and higher mortality (4/31 [12.9%] vs 5/250 [2%]; p = 0.010). Within the super-refractory status epilepticus group, status epilepticus resolution was attained with a single continuous infusion in 15 of 31 patients (48.4%), two in 10 of 31 (32.3%), and three or more in six of 31 (19.4%). Most super-refractory status epilepticus patients (30/31, 96.8%) received midazolam as first choice. About 17 of 31 patients (54.8%) received additional treatments.</p>

<p><strong>CONCLUSIONS: </strong>Super-refractory status epilepticus patients had delayed initiation of nonbenzodiazepine antiseizure medication treatment, higher number of medical complications and mortality, and lower return to neurologic baseline than nonsuper-refractory status epilepticus patients, although these associations were not adjusted for potential confounders. Treatment approaches following the first continuous infusion were heterogeneous, reflecting limited information to guide clinical decision-making in super-refractory status epilepticus.</p>

DOI

10.1097/PCC.0000000000002786

Alternate Title

Pediatr Crit Care Med

PMID

34120133
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Title

Treatment of Neonatal Seizures: Comparison of Treatment Pathways From 11 Neonatal Intensive Care Units.

Year of Publication

2022

Number of Pages

67-74

Date Published

2022 03

ISSN Number

1873-5150

Abstract

<p><strong>OBJECTIVE: </strong>Seizures are a common neonatal neurologic emergency. Many centers have developed pathways to optimize management. We evaluated neonatal seizure management pathways at level IV neonatal intensive care units (NICUs) in the United States to highlight areas of consensus and describe aspects of variability.</p>

<p><strong>METHODS: </strong>We conducted a descriptive analysis of 11 neonatal seizure management pathways from level IV NICUs that specialize in neonatal neurocritical care including guidelines for electroencephalography (EEG) monitoring, antiseizure medication (ASM) choice, timing, and dose.</p>

<p><strong>RESULTS: </strong>Study center NICUs had a median of 70 beds (interquartile range: 52-96). All sites had 24/7 conventional EEG initiation, monitoring, and review capability. Management pathways uniformly included prompt EEG confirmation of seizures. Most pathways included a provision for intravenous benzodiazepine administration if either EEG or loading of ASM was delayed. Phenobarbital 20 mg/kg IV was the first-line ASM in all pathways. Pathways included either fosphenytoin or levetiracetam as the second-line ASM with variable dosing. Third-line ASMs were most commonly fosphenytoin or levetiracetam, with alternatives including topiramate or lacosamide. All pathways provided escalation to continuous midazolam infusion with variable dosing for seizures refractory to initial medication trials. Three pathways also included lidocaine infusion. Nine pathways discussed ASM discontinuation after resolution of acute symptomatic seizures with variable timing.</p>

<p><strong>CONCLUSIONS: </strong>Despite a paucity of data from controlled trials regarding optimal neonatal seizure management, there are areas of broad agreement among institutional pathways. Areas of substantial heterogeneity that require further research include optimal second-line ASM, dosage, and timing of ASM discontinuation.</p>

DOI

10.1016/j.pediatrneurol.2021.10.004

Alternate Title

Pediatr Neurol

PMID

34750046
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Title

Expanding Access to Continuous EEG Monitoring in Neonatal Intensive Care Units.

Year of Publication

2020

Number of Pages

Date Published

2020 Jun 09

ISSN Number

1537-1603

Abstract

<p><strong>PURPOSE: </strong>Neonatal seizures are common and difficult to identify clinically because the majority are subclinical and correct identification of electroclinical seizures based on semiology is unreliable. Therefore, continuous EEG monitoring (CEEG) is critical for seizure identification in neonates and is recommended as the gold standard method in American Clinical Neurophysiology Society guidelines. Despite these recommendations, barriers to implementing widespread CEEG exist.</p>

<p><strong>METHODS: </strong>To expand access to CEEG for at-risk neonates, a framework for providing remote CEEG was established at two network hospital neonatal intensive care units. Utilization and clinical impact were tracked as a quality improvement study.</p>

<p><strong>RESULTS: </strong>In a 27-month period from June 2017 through September 2019, 76 neonates underwent CEEG between the two network neonatal intensive care units. Electrographic seizures occurred in about one quarter of records (18/76; 24%), though their incidence varied by CEEG indication. Care notes indicated that CEEG impacted clinical care in three quarters of cases (57/76; 75%). Continuous EEG impacted decisions to treat with anti-seizure medications in approximately one half of patients (impact: 28/57 [49%]; no impact 29/57 [51%]), and CEEG impacted prognostic discussions in approximately two thirds of patients (impact: 39/57 [68%]; no impact 18/57 [32%]).</p>

<p><strong>CONCLUSIONS: </strong>Establishment of a remote CEEG program for neonates is feasible, effective at identifying seizures, and improves the quality of care provided to neonates hospitalized at these network hospitals.</p>

DOI

10.1097/WNP.0000000000000730

Alternate Title

J Clin Neurophysiol

PMID

32541608
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