Secondary Generalization Research Articles

Sustainable urban development policies and practices in the United States

Sustainability approaches have a special significance in terms of ensuring a long-term and balanced multi-dimensional urban development. The purpose of the study is to reveal and describe the main features of sustainable urban development in the United States in terms of urban policymaking and practical implementation. In the theoretical part of the paper, various interpretations of sustainable urban development and sustainable cities were discussed and summarized. Meanwhile, a brief description of the current state of global urbanization processes was given. Through secondary data analysis (governmental reports, descriptions of missions and target activities, legislative acts, etc.), comparison and generalization, the main actors (governmental bodies at federal level) and priorities of the U.S. urban policy with a special focus on sustainability were identified and discussed. In addition, the framework of the U.S. sustainable urban development policymaking was suggested and generalized. Different city rankings (based on sustainable development goals, green development, etc.) reveal the leading role of Pacific Coast urban areas, Washington D.C., Boston and New York City in terms of urban sustainability practices. Various urban innovations are implemented in the same and other urban areas, promoting the further development of smart sustainable city concept in the United States.

The role of vagal nerve stimulation on psychosocial associated disorders in refractory epilepsy patients.

To determine the effects of vagal nerve stimulation on cognition and epilepsy-associated psychosocial problems in patients with intractable epilepsy, and to assess their relation to seizure decline. The longitudinal study was conducted at Saad Al-Witry Neurosciences Hospital, Baghdad, Iraq, from December 2015 to December 2020, and comprised refractory epilepsy cases with implanted vagal nerve stimulation devices. They were subjected to pre- and post-implantation epilepsy protocol assessment with added neuropsychological evaluation using the Mini-Mental State Examination system. Each case was followed up for 2 years post-implantation. Descriptive data regarding patient records of age, seizure nature, mental functioning level, and vagal nerve stimulation insertion was noted. Data was analysed using SPSS 21. Of the 150 patients, 75(50%) each were males and females, with 70(46.7%) aged <10 years at the time of surgery. Overall, 80(53.3%) patients had partial seizures with secondary generalisation, 70(46.7%) had refractory seizure attacks for <5 years, 78(52%) had attack frequency of 2-5 per day. All 150(100%) patients had had vagal nerve stimulation for >2 years. Post-intervention, 80(53.3%) patients had <2 attacks per day. Mini-Mental State Examination score was >25 in 35(23.3%) patients which post-intervention rose to 64(42.7%). There was evidence of improvement with respect to patient characteristics predictive of vagal nerve stimulation-related cognition and neuropsychological responsiveness in refractory epilepsy.

Clinical pharmacy and telemedicine: an opportunity to improve epilepsy management.

Clinical pharmacy, as defined by the European Society of Clinical Pharmacy, is a comprehensive professional practice encompassing all pharmacist profiles regardless of the setting. It focuses on promoting optimal drug utilization for patient-centric clinical outcomes. Telemedicine leverages information and communication technologies for remote healthcare delivery, bridging geographical gaps. The integration of clinical pharmacy and telemedicine is crucial in modern healthcare paradigms, especially for patients with chronic illnesses. In 2021, marketing authorization was granted for cenobamate as adjunctive treatment for focal-onset seizures with or without secondary generalization in adults with epilepsy who have not been adequately controlled despite a history of treatment with at least two antiepileptic medicinal products. This review emphasizes the synergistic role of clinical pharmacists and neurologists in utilizing telemedicine for patient counselling, drug information dissemination, adverse drug reaction surveillance, and personalized medication management within the context of epilepsy care. This integration could enhance patient safety, therapeutic outcomes and address socio-economic challenges faced by chronic patients.

Incidence and determinants of seizures in multiple sclerosis: a meta-analysis of randomised clinical trials

BackgroundSeizures are reported to be more prevalent in individuals with multiple sclerosis (MS) compared with the general population. Existing data predominantly originate from population-based studies, which introduce variability in methodologies...

Efficacy, safety, and tolerability of adjunctive brivaracetam in adult Asian patients with uncontrolled focal-onset seizures: A phase III randomized, double-blind, placebo-controlled trial.

Evaluate efficacy, safety, and tolerability of adjunctive brivaracetam (BRV) in adult Asian patients with focal-onset seizures (FOS). Phase III, randomized, double-blind, placebo-controlled study (EP0083; NCT03083665) evaluating BRV 50 mg/day and 200 mg/day in patients (≥16-80 years) with FOS with/without secondary generalization (focal to bilateral tonic-clonic seizures) despite current treatment with 1 or 2 concomitant antiseizure medications. Following an 8-week baseline, patients were randomized 1:1:1 to placebo, BRV 50 mg/day, or BRV 200 mg/day, and entered a 12-week treatment period. Efficacy outcomes: percent reduction over placebo in 28-day FOS frequency (primary); 50% responder rate in FOS frequency; median percent reduction in FOS frequency from baseline; seizure freedom during treatment period (secondary). Primary safety endpoints: incidences of treatment-emergent adverse events (TEAEs); TEAEs leading to discontinuation; serious TEAEs. In this study, 448/449 randomized patients (mean age, 34.5 years; 53.8% female) received ≥1 dose of study medication (placebo/BRV 50 mg/BRV 200 mg/day: n = 149/151/148). Percent reduction over placebo in 28-day adjusted FOS frequency was 24.5% (p = 0.0005) and 33.4% (p < 0.0001) with BRV 50 mg/day and 200 mg/day, respectively, 50% responder rate was 19.0%, 41.1%, and 49.3% with placebo, BRV 50 mg/day, and BRV 200 mg/day, respectively (p < 0.0001 for both BRV groups vs. placebo). Median percent reduction in FOS frequency from baseline was 21.3%/38.9%/46.7% in patients on placebo/BRV 50 mg/BRV 200 mg/day, respectively. Overall, 0, 7 (4.6%), and 10 (6.8%) patients were classified as seizure-free during the treatment period on placebo, BRV 50 mg/day, and BRV 200 mg/day, respectively (p = 0.0146/p = 0.0017 for BRV 50 mg/200 mg/day vs. placebo, respectively). TEAE incidences were similar between patients on placebo (58.4%) and all patients receiving BRV (58.5%); TEAE incidences for BRV 50 mg/day and BRV 200 mg/day were 57.0% and 60.1%, respectively. Overall, 0.7% of patients on placebo and 2.0% of all patients on BRV reported serious TEAEs (incidences for BRV 50 mg/day and BRV 200 mg/day were 1.3% and 2.7%, respectively), 20.1% of patients on placebo and 33.1% of all patients on BRV reported drug-related TEAEs (incidences for BRV 50 mg/day and BRV 200 mg/day were 26.5% and 39.9%, respectively), and 4.7% of patients on placebo and 3.0% of all patients on BRV discontinued due to TEAEs (discontinuation incidences for BRV 50 mg/day and BRV 200 mg/day were 2.6% and 3.4%, respectively). Adjunctive BRV was efficacious and well tolerated in adult Asian patients with FOS. Efficacy and safety profiles were consistent with BRV studies in predominantly non-Asian populations. Brivaracetam is used to treat partial or focal seizures in people with epilepsy. Most studies with brivaracetam tablets have involved people from non-Asian racial backgrounds. In this study, 449 Asian adults with epilepsy took part. One third took 50 mg of brivaracetam, one third took 200 mg of brivaracetam, and one third took a placebo each day for 12 weeks. On average, those who took brivaracetam had fewer seizures than those given the placebo. Most of the side effects were mild and the number and type of side effects seen were as expected for this medication.

Post-Ictal Mania: A Case Report with Literature Revue

IntroductionWhile postictal mania is a well-recognized clinical condition, it has received less research attention compared to other postictal manifestations.ObjectivesDrawing upon an analysis of a case report that underscores the clinical and therapeutic challenges associated with comorbid epilepsy and mania, a literature review was carried out to investigate the connection between these two disorders.MethodsWe illustrate a case of comorbidity between mania and epilepsy and provide a concise review of the literature summarizing the key characteristics of this association.ResultsThis case pertains to Mr. M, a 44-year-old male with a history of frontal epilepsy characterized by secondary partial generalization, which was partially controlled with sodium valproate. He was admitted to our service due to acute agitation following a loss of consciousness lasting a few minutes.Upon admission, the patient exhibited symptoms of mental confusion. A neurological examination did not uncover any abnormalities. Brain computed tomography revealed mild frontal atrophy. Video electroencephalography conducted during the interictal period and outside the episodes of confusion did not reveal any abnormalities. The patient was restarted on sodium valproate (20 mg/kg/day) and clonazepam (2 mg/day). Following a lucid interval of ten days, the patient started to manifest psychiatric symptoms, which included irritability, hostility towards his spouse, increased talkativeness, thought pressure, and an unusual sense of familiarity, raising suspicion of post-ictal mania.ConclusionsBased on this clinical case and the existing scientific literature, post-ictal mania occupies a distinct position among the mental disorders observed in the post-ictal period. Therefore, clinicians must be aware of these conditions to facilitate accurate diagnosis and appropriate management.Disclosure of InterestNone Declared

High-resolution intraoperative infrared thermography for the functional imaging and tumor resection maximization of a low-grade glioma: Technical case report

Currently, it is widely recognized the role of the extent of resection on overall and progression-free survival for gliomas surgery. Brain mapping and intraoperative image guidance are generally required to attain such an objective. Infrared Thermography (IRT) has a potential role in the identification of surgical margins, but it has not been consistently assessed in the literature. We aim to demonstrate the use of intraoperative IRT to detect superficial and deep tumoral margins of low-grade glioma, to identify adjacent functional motor cortex, and to maximize surgical resection in a 45-year-old lady with a long history of partial and secondary generalization seizures.

Is High-Frequency Activity at Seizure Onset Inhibitory? A Stereoelectroencephalographic Study of Motor Cortex Seizures.

In the era of stereoelectroencephalography (SEEG), many studies have been devoted to understanding the role of interictal high-frequency oscillations. High-frequency activity (HFA) at seizure onset has been identified as a marker of epileptogenic zone. We address the physiological significance of ictal HFAs and their relation to clinical semiology. We retrospectively identified patients with pure focal primary motor epilepsy. We selected only patients in whom SEEG electrodes were optimally placed in the motor cortex as confirmed by electrical stimulation. Based on these narrow inclusion criteria, we extensively studied 5 patients (3 males and 2 females, mean age = 22.4 years) using time-frequency analysis and time correlation with motor signs onset. A total of 157 analyzable seizures were recorded in 5 subjects. The first 2 subjects had tonic or clonic semiology with rare secondary generalization. Subject 3 had atonic onset followed by clonic hand/arm flexion. Subject 4 had clusters of tonic and atonic facial movements. Subject 5 had upper extremity tonic movements. The median frequency of the fast activity extracted from the Epileptogenic Zone Fingerprint pipeline in the first 4 subjects was 76 Hz (interquartile range = 21.9Hz). Positive motor signs did not occur concomitantly with high gamma activity developing in the motor cortex. Motor signs began at the end of HFAs. This study supports the hypothesis of an inhibitory effect of ictal HFAs. The frequency range in the gamma band was associated with the direction of the clinical output effect. Changes from inhibitory to excitatory effect occurred when discharge frequency dropped to low gamma or beta. ANN NEUROL 2024;95:1127-1137.

Physiologically Based Pharmacokinetic Modeling of Lacosamide in Patients With Hepatic and Renal Impairment and Pediatric Populations to Support Pediatric Dosing Optimization

PurposeLacosamide (LCM) is a new-generation anti-seizure medication that is efficacious in patients with focal seizures with or without secondary generalization. Until now, the efficacy, safety, and tolerability of LCM are still lacking in Chinese epilepsy patients, particularly for pediatric populations and patients with renal or hepatic impairment. MethodsThis study was conducted to develop a physiologically based pharmacokinetic (PBPK) model to characterize the pharmacokinetics of LCM in Chinese populations and predict the pharmacokinetics of LCM in Chinese pediatric populations and patients with renal or hepatic impairment. Using data from clinical investigations, the developed PBPK model was validated by comparing predicted and observed blood concentration data. FindingsDoses should be reduced to approximately 82%, 75%, 63%, and 76% of the Chinese healthy adult dose in patients with mild, moderate, and severe renal impairment and end-stage renal disease; and approximately 89%, 72%, and 36% of the Chinese healthy adult dose in patients with Child Pugh-A, B, and C hepatic impairment. For pediatric populations, intravenous doses should be adjusted to 1.75 mg/kg for newborns, 2.5 mg/kg for toddlers, 2.2 mg/kg mg for preschool and school age, and 2 mg/kg mg for adolescents to achieve an equivalent plasma exposure of 2 mg/kg LCM in adults. The oral doses should be adjusted to 20 mg for toddlers, 32 mg for preschool, 45 mg for school age, and 95 mg for adolescents to achieve an approximately equivalent plasma exposure of 100 mg LCM in adults. ImplicationsThe PBPK model of LCM can be utilized to optimize dosage regimens for special populations.

Study of the practice of prescribing phenosanic acid in epilepsy accompanied by asthenic disorders

To evaluate the experience of prescribing phenosanic acid in the practice of a neurologist/epileptologist when prescribing the second, third anticonvulsant drug (AED) as part of combination therapy for patients with manifestations of fatigue due to epilepsy. 501 patients with focal epilepsy accompanied by asthenic disorders were included in the observational program. The observation program protocol included 5 visits, including visit 1, at which screening and inclusion in the OP took place. The observation period was 10 months. At baseline and at the end of the 10-month follow-up, the patients' condition was assessed according to the following indicators: frequency and transformation of attacks with focal onset, severity of fatigue (self-assessment scale MFI-20); quality of life (questionnaire QoLiE-10-P); frequency of attacks with focal onset. The safety of phenosanic acid (Dibufelon) was also assessed. In 10 months after the inclusion of Dibufelon as the 2nd, 3rd AED in the treatment regimen, a statistically significant (p<0.01) decrease in the frequency of seizures was observed: in general - in 88% of patients; by 50% or more - in 76% of patients; transition from the group with a large number of seizures to the group with a smaller number of seizures - 74% of patients. Also when taking phenosanic acid, a positive dynamics of seizure type was noted: a reliable decrease in the proportion of patients with seizures with secondary generalization from 70% to 56%; a decrease in the number of focal seizures with impaired consciousness from 65% to 53%. In addition, there was a 38% decrease in the severity of fatigue on the MFI-20 scale (the greatest decrease on the «Mental fatigue» scale), improvement in the quality of life - a 2.7-fold increase in the mean values of the QOLIE-10 questionnaire. The addition of phenosanic acid to antiepileptic therapy as a second or third AED allows for better control of seizures, leading to a decrease the frequency and severity of attacks and the severity of fatigue both, and an increase of the quality of life of patients with epilepsy.

The Role of Government Policies in Fostering Entrepreneurship and Innovation in India

The purpose of the present study is to find out the role of government in bringing innovation and encouraging entrepreneurship in developing country like India. Despite of having great potential India still faces the problem of unemployment with rising population. There is no doubt that with rising GDP and increasing exports India will become an economic powerhouse by 2047 but it must overcome certain challenges. Therefore, it becomes necessary to find out those challenges and suggest measures to overcome them becomes the aim of the present study. The methodology used to study those challenges is through secondary data analysis and generalizations are drawn after analyzing them. The findings of the study reveal that India has barriers to innovation in terms of knowledge, finance, and marketing. Also, the patents filed as far less in India then other developed economies. Since India huge potential and lots of initiatives led by the government for innovation and benefits for entrepreneurs need to overcome those barriers. The practical implications of the study are for future researchers to identify the barriers and give measures to overcome them so that India improves itself in terms of innovation and entrepreneurship.

Quantification of Oxcarbazepine Using Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS).

Oxcarbazepine (Trileptal®) has been found effective in the treatment of tonic-clonic seizures and partial seizures with or without secondary generalization, with fewer side effects than traditional therapy. Oxcarbazepine is a keto analogue of carbamazepine. It is rapidly reduced to 10-monohydroxy carbamazepine (MHD), its active metabolite. This assay measures concentrations for oxcarbazepine metabolite (MHD), internal standard (MHD 13C6) solution is added to all the patient specimens resulting in precipitation of proteins. The analytes are separated using a Phenomenex Kinetex C18 column and are detected with a mass spectrophotometer utilizing multiple reaction monitoring (MRM). The analytes are qualitatively identified and quantitated from a calibration curve generated from calibrators included in the run.

The Role of Thymoma and Thymic Hyperplasia as Prognostic Risk Factors for Secondary Generalisation in Adults with Ocular Myasthenia Gravis: A Systematic Narrative Review.

The conversion of ocular myasthenia gravis (OMG) to generalised myasthenia gravis (GMG) is reported to differ depending on the presence of generalisation risk factors (Mazzoli et al. 2018). Thymic pathology has been recognised as a potential risk factor for generalisation in the literature (Teo et al. 2017). Thymoma and thymic hyperplasia have yet to be examined as a risk factor for generalisation of OMG independently of other risk factors in the literature. Thus, the purpose of this review is to examine the literature to identify whether thymoma and thymic hyperplasia do increase the risk of OMG progressing to GMG. A literature search was carried out which employed a systematic approach. The search was undertaken using the following academic libraries: MEDLINE, Embase and Starplus. The search was limited to publications between the years 2001 to 2021. The search yielded 82 studies, which after the screening of titles and abstracts, left 62 studies for further analysis against the inclusion and exclusion criteria. The review found thymoma to be associated with an increased risk of GMG development. However, there was a scarce amount of literature which investigated thymic hyperplasia. Therefore, a firm conclusion could not be made with regards to thymic hyperplasia and the risk of GMG development. This review provides evidence for the consideration of thymectomy early after thymomatous OMG diagnosis to prevent GMG conversion. As the review did not collect enough evidence to support the influence of thymic hyperplasia on OMG conversion, further research is required.

Lafora disease presented with multiple seizure

Among different types of Progressive Myoclonic Epilepsy (PME), Lafora disease is an autosomal recessive disorder, with age of onset 6-19 years. It is quickly progressive, and death occurs within 10 years. It is a glycogen metabolism disorder characterized by the presence of inclusion bodies, known as Lafora bodies within the cytoplasm of the skin, liver, breast and muscle. Lafora disease presents as a neurodegenerative disorder with difficult to control seizures mostly like progressive myoclonic epilepsy. But the disease may also present with multiple types of seizures like generalized tonic clonic, focal with secondary generalization, myoclonic, absence etc. Patient may also present with psychomotor regression with ataxia, dysarthria, dementia, visual hallucination etc. Electroencephalogram (EEG) shows generalized spike/ polyspikes and waves with photosensitivity and background slowing. Diagnosis is further confirmed by presence of inclusion bodies (Lafora body) with typical histological findings on skin biopsy and genetic testing. Here we present a case of Lafora disease that presented with progressive myoclonic epilepsy and generalized tonic clonic seizure. We took proper history, did meticulous clinical examination and investigated her at our institute. We confirmed the patient having Lafora disease with typical histological findings that is presence of Lafora body on skin biopsy taken from axilla. Then treatment was given to the patient accordingly and proper counseling was done about the disease and its prognosis. J Bangladesh Coll Phys Surg 2023; 41(4): 329-333

AGR - 3 Epilepsy Surgical Planning in a Patient with Co-Morbid Multiple Sclerosis and Seizures.

Research increasingly points to historically unappreciated cortical effects of multiple sclerosis (MS), with two-fold elevated risk of seizures. Nevertheless, epilepsy only occurs in 2-5% of cases. We present a 42-year-old, right-handed, woman with epilepsy and MS under consideration for epilepsy surgery. Epilepsy and MS were diagnosed concurrently at age 31; seizures were the presenting symptom. Despite infrequent MS flares, seizures are weekly-to-monthly focal aware, focal unaware and focal-to-bilateral, starting with right head version, dysarthria, and spinning, followed by secondary generalization, at times occurring in clusters. Brain MRI revealed bilateral MS lesions including in left medial-frontal lobe and left hippocampus (Figure 1). Phase I EEG suggested left-lateralized seizures with broad frontotemporal evolution and rapid bifrontal synchrony. Interictal PET was unrevealing. fMRI determined left-hemisphere language dominance. Neuropsychological evaluation (NPE) was ordered to estimate cognitive risks of left-sided surgery. NPE revealed relatively intact language and verbal learning/memory with exceptionally low visual learning/memory. Visuospatial skills were below average to exceptionally low. Although motor dexterity was exceptionally low bilaterally, her left-hand was markedly slower. Executive functioning, processing speed, and sustained attention were exceptionally low. Risk stratification drew upon traditional epilepsy surgery outcomes, as only 2 cases of epilepsy surgery in vastly different MS patients have been published. NPE suggested high functional adequacy of the left hemisphere with low functional reserve of the right hemisphere. Due to paradoxical findings across structural/functional brain imaging, EEG, and NPE, with unclear effects/implications of MS, cautions were raised about surgery. Stereo-EEG and magnetoencephalography were recommended/ordered to determine the safest surgical option.

Gabapentin monotherapy for epilepsy: A review.

Epilepsy is one of the most common chronic neurological disorders, affecting more than 50 million people globally. In this review we summarised the evidence from randomised controlled trials of gabapentin used as monotherapy for the treatment of focal epilepsy, both newly diagnosed and drug-resistant, with or without secondary generalisation. To assess the effects of gabapentin monotherapy for people with epileptic focal seizures with and without secondary generalisation. We searched the Cochrane Register of Studies (CRS Web) and MEDLINE (Ovid, 1946 to 24 February 2020) on 25 February 2020. CRS Web includes randomised or quasi-randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, the Cochrane Central Register of Controlled Trials (CENTRA), and the specialised registers of Cochrane Review Groups including the Cochrane Epilepsy Group. We also searched several Russian databases, reference lists of relevant studies, ongoing trials registers, conference proceedings, and we contacted trial authors. We found five randomised controlled trials (3167 participants) comparing gabapentin to other antiepileptic drugs (AEDs) and differing doses of gabapentin as monotherapy for newly diagnosed focal epilepsy and drug- resistant focal epilepsy with or without secondary generalisation. Two review authors independently applied the inclusion criteria, assessed trial quality, risk of bias, and extracted data. We used the GRADE approach to assess the certainty of evidence and present seven patient-important outcomes in the "Summary of findings" tables. The quality of evidence was very low to moderate due to poor reporting quality, poor trial design, and other risks of bias, such as selective presentation of findings and potential heavy industry input. Better quality research may change our certainty in the effect estimates. None of the included trials reported on the number of people with 50% or greater reduction in seizures and time to withdrawal (retention time) in an extractable way. Gabapentin-treated participants were more likely to withdraw from treatment for any cause (285/539) than those treated with lamotrigine, oxcarbazepine, or topiramate pooled together (695/1317) (RR 1.13, 95% CI 1.02 to 1.25; 3 studies, 1856 participants; moderate-certainty evidence), but not carbamazepine. Fewer people treated with gabapentin withdrew from treatment owing to adverse events (190/525) than those treated with carbamazepine, oxcarbazepine, or topiramate (479/1238), (RR 0.79, 95% CI 0.69 to 0.91; 1763 participants, 3 studies; moderate-certainty evidence), but not lamotrigine.CONCLUSIONGabapentin as monotherapy probably controlled seizures no better and no worse than comparator AEDs (lamotrigine, carbamazepine, oxcarbazepine, and topiramate). Compared to carbamazepine, gabapentin was probably better in retaining people in studies and preventing withdrawals due to adverse events. The most common side effects associated with gabapentin were ataxia (poor co-ordination and unsteady gait), dizziness, fatigue, and drowsiness.

Clinical Characteristics Associated With Secondary Generalization in Patients With Ocular Myasthenia Gravis: A Systematic Review and Meta-analysis.

Ocular myasthenia gravis (OMG) is an autoimmune disorder resulting in ocular symptoms such as diplopia and ptosis. The proportion of patients who convert to secondary generalized myasthenia gravis (SGMG) reported in the literature has been varied. The aim of this systematic review was to determine the clinical characteristics of patients with OMG and the proportion of SGMG conversion. We conducted an electronic database search for randomized controlled trials, prospective nonrandomized studies, observational studies, and retrospective studies in EMBASE, CENTRAL, MEDLINE, and Web of Science. We included studies with patients with OMG who initially presented with ocular symptoms and signs only and were seen in clinical practice, reporting on the characteristics and outcomes of SGMG. We excluded studies with pediatric and congenital myasthenia gravis populations. Eligible studies included articles written in any language and containing data on patients with OMG. The main outcome measured was the proportion of patients with OMG who converted to SGMG and risk factors associated with secondary generalization of OMG. Two independent reviewers screened titles and abstracts and extracted data from full texts, reporting findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The methodology was evaluated using the Joanna Briggs Institute critical appraisal forms. PROSPERO registration number: CRD2021285257. Thirty-one studies were included in the quantitative and qualitative analysis. The proportion of generalization ranged from 11% to 84%. The pooled proportion was 39% (95% CI 32%-47%, I 2 = 95.86%, p < 0.001 unweighted, low certainty). The pooled risk ratio of female sex for conversion to SGMG was 1.06 (95% CI 0.96-1.17, I 2 = 0% p = 0.614, 21 studies included, very low certainty), and the pooled risk ratio of acetylcholine receptor (AChR) positivity was 1.30 (95% CI 1.05-1.56, I 2 = 0% p = 0.455, 16 studies included, very low certainty). Risk factors such as female sex and anti-AChR positivity have been identified to have possible associations with SGMG, but there are not enough quality observational studies. There is a need for a prospective global database of patients with OMG, including all countries with different populations.

Intracortical functional connectivity dynamics induced by reflex seizures

Functional connectivity analysis is gaining more interest due to its promising clinical applications. To study network mechanisms underlying seizure termination and postictal depression, we explore dynamics of interhemispheric functional connectivity near the offset of focal and bilateral seizures in the experimental model of reflex audiogenic epilepsy. In the model, seizures and spreading depression are induced by sound stimulation of genetically predisposed rodents. We characterize temporal evolution of seizure-associated coupling dynamics in the frontoparietal cortex during late ictal, immediate postictal and interictal resting states, using two measures applied to local field potentials recorded in awake epileptic rats. Signals were analyzed with mean phase coherence index in delta (1–4 Hz), theta (4–10 Hz) beta (10–25 Hz) and gamma (25–50 Hz) frequency bands and mutual information function. The study shows that reflex seizures elicit highly dynamic changes in interhemispheric functional coupling with seizure-, region- and frequency-specific patterns of increased and decreased connectivity during late ictal and immediate postictal periods. Also, secondary generalization of recurrent seizures (kindling) is associated with pronounced alterations in resting-state functional connectivity – an early wideband decrease and a subsequent beta-gamma increase. The findings show that intracortical functional connectivity is dynamically modified in response to seizures on short and long timescales, suggesting the existence of activity-dependent plastic network alterations that may promote or prevent seizure propagation within the cortex and underlie postictal behavioral impairments.

Paroxysmal sympathetic hyperactivity in a child with stroke: a case report

BackgroundParoxysmal sympathetic hyperactivity (PSH) is the result of dysregulated autonomic function with sympathetic symptoms characterised by increased heart rate, respiratory rate, blood pressure and temperature with abnormal posture, which predominately occur periodically but can be persistent in severe cases. Common causes that present in similar fashion such as infectious process (bacteremia, meningitis, etc.); non-PSH neurological deterioration (increased intracranial pressure, intracranial haemorrhage, intracranial oedema, seizures, encephalitis); pulmonary embolism; thyrotoxicosis, alcohol or drug withdrawal; neuroleptic malignant syndrome; serotonin syndrome; and malignant hyperthermia need to be excluded before diagnosing PSH. The earlier the diagnosis made, the better the prognosis.Case presentationWe report a case of a 3-year-old male child who was a diagnosed case of Tetralogy of Fallot presented with left focal seizure with secondary generalisation. Child also had respiratory complaints prior to convulsion. He had developed signs of raised intracranial pressure. Blood culture sent to rule out infective endocarditis was negative. CT brain showed bilateral diffuse cortical infarct. Child developed signs and symptoms of PSH such as fever, tachycardia, tachypnoea, hypertension, diaphoresis, dystonia and bilateral completely dilated pupils. Other common causes such as infective endocarditis, increased intracranial pressure, intracranial oedema, intracranial haemorrhage, seizure, encephalitis and infectious processes (bacteremia, meningitis and infective endocarditis) were ruled out. The diagnosis of PSH was made and started on propranolol along with clonidine. Child responded well to the treatment.ConclusionThe complex pathophysiology of PSH warrants extensive work-up to rule out other common causes. The outcome of our patient shows the importance of early diagnosis and multidisciplinary treatment for better outcome.

Equipotency of lacosamide to levetiracetam in new onset focal epilepsy: A randomized controlled trial.

Levetiracetam (LEV) is a well-established broad spectrum antiseizure medication (ASM) effective in focal, generalized, and myoclonic seizures whereas lacosamide (LCM) is a comparatively newer ASM currently approved only as an add-on agent in focal seizures. The aim of the study was to assess the efficacy and the tolerability of oral LCM as monotherapy in adult people with epilepsy (PWE) with new onset focal onset epilepsy compared with those receiving LEV. In this open-label single-center non-inferiority trial, PWE aged between 16 and 65 years suffering from new onset focal seizures, with or without secondary generalization were put on LCM monotherapy or LEV monotherapy. Data regarding demographic characteristics, seizure type and etiology, LCM and LEV daily dose, seizure frequency at baseline and at 6 months of follow-up, and seizure freedom rates were recorded. Thirty-five PWE on LCM (24 males), their mean age: 38.20 ± 16.62 years and 35 PWE on LEV (25 males, mean age: 38.91 ± 17.13 years) were enrolled. The most common type of seizure observed was focal to bilateral tonic-clonic seizure >70% followed by focal impaired awareness seizure and focal awareness seizure. Structural epilepsy was found in 21 among LCM group and 22 of LEV group. In the LCM group, the seizure frequency decreased from 3.33 ± 1.88 to 0.85 ± 1.09 (P = 0.001) at 6 months and from 3.61 ± 3.12 to 0.94 ± 1.24 (P = 0.001) in LEV group, intergroup difference (P = 0.74). At 6-month follow-up period, 78.9% in LCM arm and 87.9% in the LEV arm had experienced a 50% of reduction in seizure frequency while seizure freedom was attained in 43.3% of PWE in both the arms (P = 1). The most common treatment emergent adverse effects in the LCM group were fatiguability, dyspepsia, headache, and dizziness, while in the LEV group; somnolence and behavioral abnormality. Treatment with LCM met the non-inferiority criteria when compared with LEV. Therefore, it might be useful as first-line monotherapy for adults with newly diagnosed focal epilepsy.