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Objectives: To systematically assess the nursing workload in an Intermediate Care Unit., Design: Single-centre prospective observational study. The nursing activities within the initial 72 h of hospitalization were recorded on a prespecified chart and standardized as activities/5 min/patient/day., Setting: This study was conducted at the Intermediate Care Unit of the Altovicentino Hospital (Italy) from September 1 to December 31, 2022., Main Outcome Measure: We considered working overload as an average number of nursing activities/5 min/patient/day higher than the 85th percentile and investigated independent risk factors associated with it., Results: A total of 183 patients were included. During their hospital stay, the average number of nursing activities per patient was 30 per 5-minute interval per day (range: 22-40). On the first day of hospitalization, the primary activities were predominantly administrative and managerial tasks. In contrast, on the second day, activities related to therapeutic management and primary care predominated. Various scores related to the patient's condition, including comorbidity, functionality, frailty, intensity, and severity, were analyzed for their association with nursing workload using multivariate analysis. However, only the National Early Warning Score was found to be an independent risk factor for nursing workload overload (OR 1.399, 95 % CI 1.205-1.624, p < 0.001)., Conclusion: The study results demonstrated a significant variation in nursing workload within the same department. Subsequent studies are necessary to confirm the ability of the National Early Warning Score in predicting nursing over workload., Implication for Clinical Practice: This study provides a detailed analysis of nursing workload in intermediate care settings, emphasizing the need for adequate resource allocation due to the potential for rapid deterioration in patients' conditions. By correlating nursing activities with patient severity indices, such as the National Early Warning Score, the findings support more effective organizational strategies to enhance care for patients at high risk of health decline., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Aim: This study aimed to compare the performance in risk prediction of various outcomes between specially trained triage nurses and the Manchester Triage System (MTS)., Design: Prospective observational study., Methods: The study was conducted from June 1st to December 31st, 2023, at the Emergency Department of Merano Hospital. Triage nurses underwent continuous training through dedicated courses and daily audits. We compared the risk stratification performed by expert nurses with that of MTS on various outcomes such as mortality, hospitalisation, and urgency defined by the physicians. Comparisons were made using the Areas Under the Receiver Operating Characteristic curve (AUROC)., Results: The agreement in code classification between the MTS and the expert nurse was very low. The AUROC curve analysis showed that the expert nurse outperformed the MTS in all outcomes. The triage nurse's experience led to statistically significant better stratification in admission rates, ICU admissions, and all outcomes based on the physician's assessment., Conclusions: The continuous training of nurses enables them to achieve better risk prediction compared to standardized triage systems like MTS, emphasizing the utility and necessity of implementing continuous training pathways for these highly specialised personnel., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Infectious states are subtle and rapidly evolving conditions observed daily in the emergency department (ED), and their prognostic evaluation remains a complex clinical challenge. Recently, estimated plasma volume status (ePVS) has been suggested to have a prognostic role in conditions where volemic alteration is central to the pathophysiology. The aim of this study was to verify whether ePVS recorded at ED admission can provide prognostic indications of 30-day mortality in patients with infection., Methods: A prospective observational study was performed between 1 January 2021 and 31 December 2021 at the ED of the Merano Hospital. All patients with infection were enrolled. ePVS values were derived from haemoglobin and haematocrit measured on the immediate arrival of patients in the ED. The predictive power of ePVS for 30-day mortality was assessed using a multivariate model adjusted for severity, comorbidity and urgency. Kaplan-Meier analysis was also performed., Results: Of the 949 patients with infection enrolled in the study (47.9%, SOFA ≥2), 8.9% (84/949) died at 30 days. The median ePVS value was higher in patients who died at 30 days than in patients who survived (5.83 vs. 4.61, p < 0.001). Multivariate analysis revealed that ePVS in both continuous and categorical form around the median was an independent risk factor for 30-day mortality even after adjusting for severity, comorbidity and urgency. Kaplan-Meier analysis confirmed an increased risk of death in patients with high ePVS values., Conclusions: ePVS recorded on ED admission of patients with infection was an independent predictor of risk for 30-day mortality., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

There are currently >51 million people with epilepsy (PWE) in the world and every year >4.9 million people develop new-onset epilepsy. The cornerstone of treatment in PWE is drug therapy with antiseizure medications (ASMs). However, about one-third of PWE do not achieve seizure control and do not respond well to drug therapy despite the use of appropriate ASMs [drug-resistant epilepsy (DRE)]. The aims of the current narrative review are to discuss the definition of DRE, explain the biological underpinnings and clinical biomarkers of this condition, and finally to suggest practical management strategies to tackle this issue appropriately, in a concise manner., Competing Interests: Declaration of competing interest No funding was received for this review. This review was presented at the 5th Qatar International Epilepsy Course in January 12th, 2023 by the authors. We thank Hamad Medical Corporation, Neurosciences and Medical Education Departments for supporting this event., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Epilepsy is a common medical condition that affects people of all ages, races, social classes, and geographical regions. Diagnosis of epilepsy remains clinical, and ancillary investigations (electroencephalography, imaging, etc) are of aid to determine the type, cause, and prognosis. Antiseizure medications represent the mainstay of epilepsy treatment: they aim to suppress seizures without adverse events, but they do not affect the underlying predisposition to generate seizures. Currently available antiseizure medications are effective in around two-thirds of patients with epilepsy. Neurosurgical resection is an effective strategy to reach seizure control in selected individuals with drug-resistant focal epilepsy. Non-pharmacological treatments such as palliative surgery (eg, corpus callosotomy), neuromodulation techniques (eg, vagus nerve stimulation), and dietary interventions represent therapeutic options for patients with drug-resistant epilepsy who are not suitable for resective brain surgery., Competing Interests: Declaration of interests AAA-P has received honoraria from Cobel Daruo, royalties from Oxford University Press, and a grant from the National Institute for Medical Research Development. SL has received both speaker's and consultancy fees from Angelini Pharma, Eisai, GW Pharmaceuticals, and UCB Pharma and has served on advisory boards for Angelini Pharma, Arvelle Therapeutics, BIAL, Eisai, and GW Pharmaceuticals. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: Catamenial epilepsy (CE) is defined as an increase in seizure frequency during specific phases of the menstrual cycle in women with epilepsy. The treatment usually includes a combination of non-hormonal and hormonal therapies. This systematic review summarizes the available data on the efficacy of progesterone and its derivates to treat CE., Methods: We performed a systematic search of the literature to identify studies reporting data on the use of progesterone and its derivatives (any type and dose) for the treatment of CE. The main outcome included the efficacy of progesterone and its derivatives on seizure frequency., Results: Nineteen articles (457 patients) were included; four were randomized controlled trials (two comparing progesterone vs placebo and two comparing norethisterone vs placebo). Progesterone was generally administered during the luteal phase (from day 15 to 25) or during perimenstrual exacerbations (from day 23 to 25), with an average dose of 10-30 mg/day to a maximum of 300 mg/day. The therapy, usually well tolerated, was ineffective in the randomized controlled trials; conversely, it was associated with an overall reduction in seizure frequency in case reports and uncontrolled studies., Conclusions: Although data from uncontrolled studies suggest that hormone therapy with progesterone may be useful in the treatment of CE, its efficacy has not been demonstrated in controlled trials. The possible antiseizure effect of progesterone could be mediated by its active metabolite allopregnanolone, making the plasmatic measurement of these hormones mandatory to evaluate efficacy. Further randomized controlled trials should investigate the efficacy of progesterone and its derivatives, addressing these pharmacological issues., Competing Interests: Declaration of Competing Interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. All the authors declare no conflict of interest., (Copyright © 2023 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

The electroencephalogram (EEG) is one of the most useful technologies for brain research and clinical neurology, characterized by non-invasiveness and high time resolution. The acquired traces are visibly displayed, but various studies investigate the translation of brain waves in sound (i.e., a process called sonification). Several articles have been published since 1934 about the sonification of EEG traces, in the attempt to identify the "brain-sound." However, for a long time this sonification technique was not used for clinical purposes. The analog EEG was in fact already equipped with an auditory output, although rarely mentioned in scientific papers: the pen-on-paper noise made by the writer unit. EEG technologists often relied on the sound that pens made on paper to facilitate the diagnosis. This article provides a sample of analog video-EEG recordings with audio support representing the strengths of a combined visual-and-auditory detection of different types of seizures. The purpose of the present article is to illustrate how the analog EEG "sounded," as well as to highlight the advantages of this pen-writing noise. It was considered so useful that early digital EEG devices could be equipped with special software to duplicate it digitally. Even in the present days, the sonification can be considered as an attempt to modify the EEG practice using auditory neurofeedback with applications in therapeutic interventions, cognitive improvement, and basic research., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Background: Assessing the risk of intracranial hemorrhage (ICH) in patients with a mild traumatic brain injury (MTBI) who are taking direct oral anticoagulants (DOACs) is challenging. Currently, extensive use of computed tomography (CT) is routine in the emergency department (ED)., Objective: This study aims to investigate whether the clinical and laboratory characteristics presented at the ED evaluation can also estimate the risk of post-traumatic ICH in DOAC-treated patients with MTBI., Methods: A retrospective observational study was conducted in three EDs in Italy from January 1, 2016 to March 15, 2020. All patients treated with DOACs who were evaluated for an MTBI in the ED were enrolled. The primary outcome of the study was the presence of post-traumatic ICH in the head CT performed in the ED., Results: Of 930 patients on DOACs with MTBI who were enrolled, 6.8% (63 of 930) had a post-traumatic ICH and 1.5% (14 of 930) were treated with surgery or died as a result of the ICH. None of the laboratory factors were associated with an increased risk of ICH. On multivariate analysis, previous neurosurgical intervention, major trauma dynamic, post-traumatic loss of consciousness, post-traumatic amnesia, Glasgow Coma Scale score of 14, and evidence of trauma above the clavicles were associated with a higher risk of post-traumatic ICH. The net clinical benefit provided by risk factor assessment appears superior to the strategy of performing CT on all DOAC-treated patients., Conclusions: Assessment of the clinical characteristics presented at ED admission can help identify DOAC-treated patients with MTBI who are at risk of ICH., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Aim: Super-refractory status epilepticus (SRSE) is a status epilepticus (SE) that continues or recurs ≥24 h after the onset of anesthesia. We aimed to identify the predictors of progression to SRSE and the risk of 30-day mortality in patients with SRSE by using a machine learning technique., Methods: We reviewed consecutive SE episodes in patients aged ≥14 years at Baggiovara Civil Hospital (Modena, Italy) from 2013 to 2021. A classification and regression tree analysis was performed to develop a predictive model of progression to SRSE in SE patients. In SRSE patients, a multivariate analysis was conducted to identify predictors of 30-day mortality., Results: We included 705 patients, 16% of whom (113/705) progressed to SRSE. Acute symptomatic hypoxic etiology and age ≤ 68.5 years predicted the highest risk (87.1%) of progression to SRSE. Etiology other than acute symptomatic hypoxic and absence of NCSE predicted the lowest risk (3.6%) of progression to SRSE. The predictive model was accurate in 96.1% of patients not evolving to SRSE and in 48.7% of those evolving to SRSE. Among patients with SRSE, 46.9% (53/113) died within 30 days compared to 25.2% (149/592) of patients without SRSE (p < 0.001). Among patients with SRSE, older age was associated with increased 30-day mortality (odds ratio 1.075; 95% confidence interval: 1.031-1.112; p = 0.001)., Conclusions: Acute symptomatic hypoxic etiology and younger age are major predictors of progression to SRSE. In patients with SRSE, older age is associated with increased risk of short-term mortality., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Purpose: To investigate the opinions of physicians about brain surgery for drug-resistant epilepsy worldwide., Methods: Practicing neurologists, psychiatrists, and neurosurgeons from around the world were invited to participate in an online survey. The survey anonymously collected data about demographics, years in clinical practice, discipline, nation, work setting, and answers to the questions about beliefs and attitudes about brain surgery for drug-resistant epilepsy., Results: In total, 1410 physicians from 20 countries and different world regions participated. The propensity to discuss brain surgery with patients, who have drug-resistant seizures, was higher among men (versus women) [Odds Ratio (OR) 1.67, 95% CI 1.20-2.31; p = 0.002]. In comparison to neurologists, psychiatrists were less likely (OR 0.28, 95% CI 0.17-0.47; p < 0.001) and neurosurgeons were more likely (OR 2.00, 95% CI 1.08-3.72; p = 0.028) to discuss about it. Survey participants working in Africa, Asia, the Middle East, and the Former Union of Soviet Socialist Republics showed a lower propensity to discuss epilepsy surgery with patients., Conclusion: This study showed that on an international level, there is still a knowledge gap concerning epilepsy surgery and much needs to be done to identify and overcome barriers to epilepsy surgery for patients with drug-resistant seizures worldwide., Competing Interests: Declaration of Competing Interest Ali A. Asadi-Pooya: Honoraria from Cobel Daruo, Ronak, and RaymandRad; Royalty: Oxford University Press (Book publication); Grant from the National Institute for Medical Research Development. Eugen Trinka has received personal fees from Arvelle/Angelini, Argenix, UCB, Eisai, Bial, Böhringer Ingelheim, Medtronic, Everpharma, Epilog, GSK, Biogen, Takeda, Liva-Nova, Newbridge, Novartis, Sanofi, Sandoz, Sunovion, GW Pharmaceuticals, Marinus; grants from Austrian Science Fund (FWF), Österreichische Nationalbank, European Union, GSK, Biogen, Eisai, Novartis, Red Bull, Bayer, and UCB; other from Neuroconsult Ges.m.b.H., outside this work. Simona Lattanzi has received speaker's or consultancy fees from Angelini, Eisai, GW Pharmaceuticals, and UCB Pharma, and has served on advisory boards for Angelini, Arvelle Therapeutics, Bial, EISAI, and GW Pharmaceuticals. Abdulaziz Ashkanani: Honoraria as a consultant/advisor & speaker for Novartis, Eli Lilly, NewBridge, and Hikma Co. Mansur Kutlubaev has received speaker's fees from Eisai. Yamile Calle-López has received fees as a speaker from UCB Pharma. Others: none., (Copyright © 2022. Published by Elsevier Ltd.)

Background: The COVID-19 pandemic brought important changes in access to the Emergency Department (ED). At present, an analysis of how the COVID-19 pandemic has changed not only the number but also the nature of the urgency of ED access is not available. This study aimed to verify the effect of the COVID-19 pandemic on the urgency of patients admitted to the ED utilizing timebased analyses., Methods: A quasi-experimental interrupted time series analysis based on a retrospective review of data from all ED admissions occurring at the Merano Hospital (Italy) from 1 January 2015 to 30 June 2021 was conducted., Results: From January 2015 to June 2021, 416,560 patients were admitted to the ED. Since the pandemic outbreak, the trend of urgent patients (classified as orange and red by triage) remained unchanged compared to the pre-pandemic period (p = 0.095, p = 0.155). In contrast, patients classified as blue (non-urgent) increased exponentially since the outbreak of the pandemic (p < 0.001)., Conclusion: The present study reported stability in urgent codes (orange and red) since the pandemic outbreak while a dramatic increase in non-urgent codes (blue and green) is reported. The results of the study may indicate the need to find health policy solutions to manage this large increase in nonurgent patients requiring assessment in EDs since the outbreak of the pandemic., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Transcranial magnetic stimulation (TMS) can be a useful tool for the assessment of the brain functional reorganization in subjects with hemiplegic cerebral palsy (HCP). In this review, we performed a systematic search of all studies using TMS in order to explore the neuroplastic changes that occur in HCP patients. We aimed at investigating the usefulness of TMS to explore cortical excitability, plasticity and connectivity changes in HCP. Children with HCP due to unilateral lesions of the corticospinal system had ipsilateral motor evoked potentials (MEPs) similar to those recorded contralaterally. TMS studies demonstrated that occupational and constraint-induced movement therapy were associated with significant improvements in contralateral and ipsilateral corticomotor projection patterns. In addition, after intensive bimanual therapy, children with HCP showed increased activation and size of the motor areas controlling the affected hand. A TMS mapping study revealed a mediolateral location of the upper and lower extremity map motor cortical representations. Deficits in intracortical and interhemispheric inhibitory mechanisms were observed in HCP. Early hand function impairment correlated with the extension of brain damage, number of involved areas, and radiological signs of corticospinal tract (CST) degeneration. Clinical mirror movements (MMs) correlated with disability and CST organization in subjects with HCP and a positive relationship was found between MMs and MEPs strength. Therefore, TMS studies have shed light on important pathophysiological aspects of motor cortex and CST reorganization in HCP patients. Furthermore, repetitive TMS (rTMS) might have therapeutic effects on CST activities, functional connectivity and clinical status in children with HCP., Competing Interests: Declaration of Competing Interest None of the authors has potential conflicts of interest to be disclosed., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Introduction: The risk of acquiring SARS-CoV-2 in a hospital setting and the need of reorganizing the Emergency Departments (EDs) to cope with infected patients have led to a reduction of ED attendances for non-infectious acute conditions and to a different management of chronic disorders., Methods: We performed a retrospective study evaluating the frequency and features of ED attendances for seizures during the lockdown period (March 10th-April 30th 2020) in the University Hospital of Trieste, Italy. We studied the possible pandemic impact on the way patients with seizures sought for medical assistance by comparing the lockdown period to a matched period in 2019 and to a period of identical length preceding the lockdown (January 18th-March 9th 2020)., Results: A striking decrease in total ED attendances was observed during lockdown (4664) compared to the matched control (10424) and to the pre-lockdown (9522) periods. A similar reduction, although to a lesser extent, was detected for seizure attendances to the ED: there were 37 during lockdown and 63 and 44 respectively during the two other periods. Intriguingly, during the lockdown a higher number of patients attended the ED with first seizures (p = 0.013), and more EEGs (p = 0.008) and CT brain scans (p = 0.018) were performed; there was a trend towards more frequent transport to the ED by ambulance (p = 0.061) in the lockdown period., Conclusions: Our data suggest that the pandemic has affected the way patients with seizures access the Health Care System., (Copyright © 2020 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Purpose: To estimate the risk of an epilepsy diagnosis after a first unprovoked seizure in dementia, in relation to the 60 % cut-off specified in the ILAE definition of epilepsy., Methods: The study was register-based. Individuals with diagnostic codes of a first unprovoked seizure were identified in the Swedish Dementia Register (SveDem) or a three times larger age- and sex- matched pool of controls (n = 1039 in SveDem and 743 controls). The risk of a diagnostic code for epilepsy was estimated by Kaplan Meier analysis., Results: The 5-year risk of a subsequent epilepsy diagnosis after a first unprovoked seizure was 32 % (95 % CI 27-37) in patients with dementia and 31 % (95 % CI 25-38) in controls. The 5-year risk of epilepsy was 48 % (95 % CI 37-59) for individuals age 70 years or below. The dementia subtype with the highest risk of epilepsy was early onset Alzheimer., Conclusion: The risk of an epilepsy diagnosis after a first unprovoked seizure is similar in patients with dementia and in controls. Our results indicate that epilepsy cannot be diagnosed after a first seizure simply on the basis of the patient having dementia. Instead, more studies are needed for individualized prediction of recurrence risk in dementia. Such studies should focus on particular dementia subtypes, younger patients, and identifying biomarkers., (Copyright © 2020 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Transcranial magnetic stimulation (TMS) may offer a reliable means of characterizing important pathophysiologic aspects of motor impairments in Parkinson's disease (PD). Moreover, high-frequency repetitive TMS (rTMS), especially if delivered bilaterally over motor cortical regions, can have beneficial effects on parkinsonian motor symptoms. However, only a few studies have investigated the effects of rTMS on freezing of gait (FOG) and other gait disturbances in PD. We aimed at investigating in this narrative review the usefulness of TMS for exploring the pathophysiology of gait impairment and at evaluating the therapeutic effects of rTMS in this context. The combination of rTMS and treadmill training was found to enhance the effect of physical therapy. Use of an H-coil enables stimulation of deep regions of the brain (for example medial prefrontal cortex) and may be used as a target for add-on therapy in the future. In contrast, theta burst stimulation has proven to be ineffective in treating gait disturbances in PD patients. Dual-mode NIBS, in particular preconditioning motor cortex rTMS by transcranial direct current stimulation, might also represent a novel therapeutic approach for patients with gait disturbances. Recent studies suggest that the supplementary motor area could be an appropriate target for brain stimulation when treating PD patients with FOG. Further large sample and well-designed clinical studies are required to evaluate how the possible positive effects of rTMS can be sustained over time and to determine the optimal stimulation protocols including target, stimulation intensity/duration and number of sessions., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: We aimed at assessing the usefulness of motor evoked potentials (MEPs) for exploring the integrity of striated sphincters and pelvic floor motor innervation in normal subjects and of repetitive transcranial magnetic stimulation TMS (rTMS) in patients with neurogenic bladder dysfunction., Methods: A systematic literature search was conducted using PubMed and Embase., Results: We identified, reviewed and discussed 11 articles matching the inclusion criteria., Conclusions: The assessment of MEPs could represent a useful tool in the investigation of patients with urologic disorders. High frequency rTMS can improve detrusor contraction and/or urethral sphincter relaxation in patients with multiple sclerosis and bladder dysfunction. Low frequency (LF) rTMS seems to be an effective treatment of neurogenic lower urinary tract dysfunctions in subjects with Parkinson's disease and possibly other neurodegenerative disorders. Furthermore, rTMS might have the potential to restore bladder and bowel sphincter function after incomplete spinal cord injury. LF rTMS could also relieve some symptoms of bladder pain syndrome and chronic pelvic pain., Significance: The clinical applicability of MEPs appears to be questionable, since a poor reproducibility was detected for all pelvic floor muscles. The use of rTMS in this field is emerging and the results of a few preliminary studies should be replicated in controlled, randomized studies with larger sample sizes., (Copyright © 2019 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Rationale: Refractory status epilepticus (RSE) is the persistence of status epilepticus despite second-line treatment. Super-refractory SE (SRSE) is characterized by ongoing status despite 48 h of anaesthetic treatment. Due to the high case fatality in RSE of 16-39%, off label treatments without strong evidence of efficacy in RSE are often administered. In single case-reports and small case series totalling 28 patients, acute implantation of VNS in RSE was associated with 76% and 26% success rate in generalized and focal RSE respectively. We performed an updated systematic review of the literature on efficacy of VNS in RSE/SRSE by including all reported patients., Methods: We systematically searched EMBASE, CENTRAL, Opengre.eu, and ClinicalTrials.gov, and PubMed databases to identify studies reporting the use of VNS for RSE and/or SRSE. We also searched conference abstracts from AES and ILAE meetings., Results: 45 patients were identified in total of which 38 were acute implantations of VNS in RSE/SRSE. Five cases had VNS implantation for epilepsia partialis continua, one for refractory electrical status epilepticus in sleep and one for acute encephalitis with refractory repetitive focal seizures. Acute VNS implantation was associated with cessation of RSE/SRSE in 74% (28/38) of acute cases. Cessation did not occur in 18% (7/38) of cases and four deaths were reported (11%); all of them due to the underlying disease and unlikely related to VNS implantation. Median duration of the RSE/SRSE episode pre and post VNS implantation was 18 days (range: 3-1680 days) and 8 days (range: 3-84 days) respectively. Positive outcomes occurred in 82% (31/38) of cases., Conclusion: VNS can interrupt RSE and SRSE in 74% of patients; data originate from reported studies classified as level IV and the risk for reporting bias is high. Further prospective studies are warranted to investigate acute VNS in RSE and SRSE., (Copyright © 2019 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To determine the best available evidence on the efficacy and tolerability of antiepileptic drugs (AEDs) used to treat poststroke seizures and epilepsy., Methods: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov and Opengrey.eu were searched for RCTs of AEDs used to treat post-stroke epilepsy. The following outcomes were considered: seizure freedom; occurrence of adverse effects (AEs); withdrawal for AEs. The methodological quality was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. Adjusted indirect comparisons were made between each AED using controlled-release carbamazepine (CR-CBZ) as common comparator., Results: Only 2 RCTs were included, one comparing levetiracetam (LEV) with CR-CBZ and the other comparing lamotrigine (LTG) with CR-CBZ. No significant difference was found in seizure freedom between either LEV or LTG and CR-CBZ. Occurrence of AEs were lower for LEV and LTG than for CR-CBZ. Indirect comparisons showed no difference between LEV and LTG for seizure freedom (OR 0.86; 95%CI: 0.15-4.89). Occurrence of AEs was higher for LEV than for LTG (OR 6.87; 95%CI: 1.15-41.1). For withdrawal rates due to AEs, we found a large width and asymmetrical distribution of confidence intervals around the obtained OR of 10.8 (95% CI: 0.78-149.71)., Conclusions: Direct and indirect comparisons did not find a difference in seizure freedom between the various AEDs, probably because of the small number of patients included. LEV and LTG appears better tolerated than CR-CBZ and LEV seems associated with more AEs than LTG. Further studies are required to provide robust evidence on efficacy and tolerability of AEDs for treating poststroke epilepsy., (Copyright © 2018 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Little is known about the relationship between epilepsy and SSc. Our study included 2431 SSc patients and 12,710 age- and sex-matched controls. In 209 controls (1.6%) and 66 SSc patients (2.7%), epilepsy diagnosis was made (not significant). In the multivariate logistic regression analysis, higher age (OR 1.01 [95% CI 1.00-1.02], p = 0.0207) was associated with an increased risk of epilepsy, whereas high vs low socioeconomic status (SES) (OR = 0.62 [95% CI 0.42-0.92], p = 0.0189) was associated with a low risk of epilepsy. In the Cox multivariate survival analysis, higher age (HR = 1.06 [95% CI 1.06-1.07], p < 0.0001), epilepsy (HR = 2.28 [95% CI 1.77-2.94], p < 0.0001) and SSc (HR = 2.37 [95% CI 2.07-2.71], p < 0.0001) were independent risk factors for all-cause mortality. In contrast, BMI >30 kg/m 2 vs BMI <20 kg/m 2 (HR = 0.69 [95% CI 0.59-0.81, p < 0.0001]), female gender (HR = 0.73 [95% CI 0.65-0.83], p < 0.0001) and high SES (HR = 0.72 [95% CI 0.63-0.82], p < 0.0001) were protective factors for mortality. SSc-related autoantibodies were not associated with the risk of epilepsy. In conclusion, whilst epilepsy and SSc are not significantly associated, epilepsy is a predictor of mortality in SSc patients., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The study aim was to evaluate the safety and efficacy of endovascular treatment (EVT) versus medical treatment (MT) in patients with symptomatic vertebral artery (VA) stenosis., Methods: Randomized controlled trials with active and control groups receiving EVT plus MT and MT alone in patients with vertebro-basilar transient ischemic attack (TIA) or stroke and VA stenosis were identified. Primary endpoints included the occurrence of any stroke, any vertebro-basilar stroke, vertebro-basilar ischemic stroke, and vertebro-basilar TIA. Secondary endpoints were myocardial infarction, vascular death, and composite vascular outcome. All endpoints were assessed at short and long-term. Risk ratios (RRs) with 95% confidence intervals (CIs) have been estimated., Results: Four trials were included involving 370 participants, 194 and 176 for EVT and MT arms, respectively. There was no overall effect of EVT on the occurrence of any stroke [short-term: RR 3.05 (95% CI 0.33-28.49); long-term: RR 0.75 (95% CI 0.40-1.40)], any vertebro-basilar stroke [short-term RR 3.05 (95% CI 0.33-28.49); long-term RR 0.91 (95% CI 0.42-1.99)], vertebro-basilar ischemic stroke [short-term: RR 1.02 (95% CI 0.07-15.88); long-term RR 1.27 (95% CI 0.36-4.50)], vertebro-basilar TIA [short-term: RR 5.00 (95% CI 0.28-90.18); long-term: RR 0.85 (95% CI 0.39-1.81)]. There were no differences across the treatments in any secondary outcome., Conclusions: There were no clear-cut benefits or harms for EVT versus MT alone in patients with symptomatic VA stenosis., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: There is increasing evidence that an involvement of central nervous system (CNS) can occur in several myopathies. Transcranial magnetic stimulation (TMS) may represent a valuable tool for investigating important neurophysiological and pathophysiological aspects of cortical involvement in neuromuscular disorders. In this review paper we aimed to perform a systematic search of the studies employing TMS techniques in subjects suffering from myopathies., Methods: A literature search was conducted using PubMed and Embase. We identified and reviewed 9 articles matching the inclusion criteria. One hundred twenty patients were included in these studies, which have applied TMS in patients with muscle disorders., Results: To date, a few studies using TMS have been performed in myopathic patients and detected subclinical abnormalities in cortical reactivity and plasticity. The most consistent finding was a decrease in intracortical inhibition, which likely represents a non-specific compensatory mechanism of the CNS in an attempt to overcome the muscle deficit through an increase of the motor cortex output to deficient muscles., Conclusions: Application of TMS to characterize the pathophysiology of the CNS in these subjects appears to be safe and may lead to the development of valuable biomarkers. Well-defined motor cortical excitability patterns can be identified in the different muscle diseases, even if preliminary findings should be confirmed in future studies in larger cohorts of patients., Significance: TMS studies may shed new light on the physiological and pathophysiological mechanisms underlying the cortical involvement in muscle disorders., (Copyright © 2017 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Olfactory dysfunction represents a frequent and disturbing non-motor manifestation of Parkinson's disease (PD). The pathophysiology of olfactory dysfunction in PD is still poorly understood. Experimental evidence suggests that olfactory impairment could be related to central cholinergic dysfunction. Short latency afferent inhibition (SAI) technique gives the opportunity to test an inhibitory cholinergic circuit in the human cerebral motor cortex. The objective of the study was to assess the cholinergic function, as measured by SAI, in PD patients with different degrees of olfactory dysfunction. We applied SAI technique in 31 patients with PD. These patients also underwent Olfactory Event-Related Potentials (OERPs) studies to objectively evaluate the olfactory system and a battery of neuropsychological tests to assess the cognitive functions. Absent OERPs indicated a severe olfactory dysfunction in 13 subjects. The presence of OERPs with an alteration in latency and/or amplitude can be considered as a borderline condition of slight alteration of smell and was found in other 15 patients. Only 3 patients showed normal OERPs. SAI was significantly reduced in the PD patients with absent OERPs compared with those with present but abnormal OERPs. Neuropsychological examination showed a mild cognitive impairment in 12 out of 13 PD patients with severe olfactory dysfunction, and in 3 out of the 15 patients with borderline olfactory dysfunction. SAI abnormalities and presence of severe olfactory impairment strongly support the hypothesis of cholinergic dysfunction in some patients with PD, who will probably develop a dementia. Longitudinal studies are required to verify whether SAI abnormalities in PD patients with olfactory dysfunction can predict a future severe cognitive decline., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Brivaracetam (BRV), eslicarbazepine acetate (ESL), lacosamide (LCM), and perampanel (PER) have been recently marketed as adjunctive treatments for focal onset seizures. To date, no randomized controlled trial (RCT) has directly compared BRV with ESL, LCM, or PER., Purpose: To compare BRV with the other add-on AEDs in patients with uncontrolled focal epilepsy, estimating their efficacy and tolerability through an adjusted, common-reference based indirect comparison meta-analysis., Methods: We systematically searched RCTs in which add-on treatment with ESL or LCM in patients with focal onset seizures have been compared with placebo. Efficacy and tolerability outcomes were considered. Random-effects Mantel-Haenszel meta-analyses were performed to obtain odds ratios (ORs) for the efficacy of BRV, LCM, ESL, or PER versus placebo. Adjusted indirect comparisons were then made between BRV and the other three AEDs using the obtained results, comparing the minimum and the highest effective recommended daily dose of each drug., Results: Seventeen RCTs, with a total of 4971 patients were included. After adjusting for dose-effects, indirect comparisons showed no difference between BRV and LCM, ESL, or PER for responder rate and seizure freedom. Lower adverse events were observed with high dose BRV compared to high dose ESL or PER, but no difference was found in withdrawing because of adverse events., Conclusions: Indirect comparisons do not demonstrate a significant difference in efficacy between add-on BRV and LCM, ESL, or PER in focal epilepsy, and might suggest a better tolerability of BRV than ESL, and possibly also PER, at the highest effective recommended dose., (Copyright © 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Minimal hepatic encephalopathy (MHE) is the earliest form of hepatic encephalopathy and can affect up to 80% of patients with liver cirrhosis. By definition, MHE is characterized by cognitive function impairment in the domains of attention, vigilance and integrative function, but obvious clinical manifestation are lacking. MHE has been shown to affect daily functioning, quality of life, driving and overall mortality. The diagnosis can be achieved through neuropsychological testing, recently developed computerized psychometric tests, such as the critical flicker frequency and the inhibitory control tests, as well as neurophysiological procedures. Event related potentials can reveal subtle changes in patients with normal neuropsychological performances. Spectral analysis of electroencephalography (EEG) and quantitative analysis of sleep EEG provide early markers of cerebral dysfunction in cirrhotic patients with MHE. Neuroimaging, in particular MRI, also increasingly reveals diffuse abnormalities in intrinsic brain activity and altered organization of functional connectivity networks. Medical treatment for MHE to date has been focused on reducing serum ammonia levels and includes non-absorbable disaccharides, probiotics or rifaximin. Liver transplantation may not reverse the cognitive deficits associated with MHE. We performed here an updated review on epidemiology, burden and quality of life, neuropsychological testing, neuroimaging, neurophysiology and therapy in subjects with MHE., (Copyright © 2016 Elsevier Ireland Ltd and Japan Neuroscience Society. All rights reserved.)

Objective: In patients with acute optic neuritis (AON) transorbital sonography may reveal a thickening of the retrobulbar portion of the optic nerve. Our aim was to systematically review the diagnostic accuracy of ultrasonography of optic nerve diameter (OND) for assessment of AON., Methods: MEDLINE, EMBASE (1966-October 2014) was searched to identify studies reporting data on patients with AON (with/without multiple sclerosis) assessed by B-mode transorbital ultrasonography. Thereafter, the studies retrieved were screened based on predefined inclusion and exclusion criteria. Data were extracted and the quality of the included studies was evaluated., Results: Seven studies (162 patients) were included. The OND was significantly thicker in the affected eye compared with its unaffected fellow or controls. An increased OND was found in 78-100% of patients. Four studies determined papilledema in 6-43% of patients., Conclusions: Transorbital sonography is a sensitive, highly accessible and user-friendly technique for the detection of significant optic nerve thickening on the side affected by AON and represents an adjunctive tool for the diagnosis of AON. Compared to visual evoked potentials, TOS may provide different, though complementary, information on the pathophysiology of AON., Significance: B-mode transorbital ultrasonography provides promising support for the clinical diagnosis of AON., (Copyright © 2015 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)

Aim: To systematically review the utility of dopamine system imaging using 123I-FP-CIT SPECT in the differential diagnosis between dementia with Lewy bodies (DLB) and other dementia syndromes., Methods: We searched MEDLINE, CENTRAL and ClinicalTrials.gov to identify studies reporting enough data to determine accuracy measure of 123I-FP-CIT SPECT in differentiating between DLB and other dementia syndromes. Studies including patients with Parkinson's disease or other parkinsonisms associated with abnormal DAT imaging were excluded. The methodological quality of studies was evaluated with QUADAS-2., Results: Eight studies were included. Studies adopting a clinical diagnosis as a reference standard showed sensitivity and specificity values of DaTSCAN in differentiating between DLB and non-DLB dementia syndromes (all subtypes, AD and FTD) consistently higher than 80%, both considering a visual and a semiquantitative analysis. The meta-analyses from the three studies using a neuropathological reference standard yielded sensitivity and specificity values higher than those adopting a clinical diagnostic reference., Conclusions: 123I-FP-CIT SPECT can represent an accurate method to differentiate between DLB and other dementia syndromes. However, most data in the literature derive from studies adopting the clinical diagnosis as the reference diagnostic standard and which are therefore intrinsically unable to demonstrate an accuracy of DAT imaging above that of careful clinical diagnosis alone. The very few studies providing information on the neuropathologic correlation for the DaTSCAN findings show however high sensitivity and specificity values, suggesting that SPECT scan is more accurate than clinical diagnosis and may prove useful in supporting the clinical diagnosis of DLB., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Purpose: High rates of poor knowledge of, and negative attitudes towards people with epilepsy (PWE) are generally found among school teachers. Their first aid epilepsy management skills are poor. It remains unknown if this is different among trainee teachers and whether educational intervention might reduce these rates. We examined the effect of health education on the knowledge, attitudes, and first aid management of epilepsy on trainee teachers in Nigeria., Methods: Baseline data and socio-demographic determinants were collected from 226 randomly selected trainee teachers, at the Federal College of Education, Lagos, Nigeria, with self-administered questionnaires. They received a health intervention comprising an hour and half epilepsy lecture followed by a discussion. Baseline knowledge of, and attitudes towards PWE and their first aid epilepsy management skills were compared to post-interventional follow-up data collected twelve weeks later with similar questionnaires., Results: At baseline the majority (61.9%) and largest proportion (44.2%) of respondents had negative attitudes and poor knowledge of epilepsy, respectively. The knowledge of, and attitudes towards epilepsy, and the first aid management skill increased in most respondents, post-intervention. The proportion of respondents with poor knowledge and negative attitudes dropped by 15.5% (p<0.0001) and 16.4% (p<0.0001) respectively. Correct knowledge concomitantly increased by 29.6% (p<0.0001) and good first aid management skills increased by 25.0% (p<0.0001) from baseline., Conclusion: Epilepsy health education could increase trainee teachers' knowledge of, and attitudes towards epilepsy and facilitate correct first aid management. This emphasizes the potential benefit of incorporating an epilepsy tailored intervention programme into teachers' training curricula., (Copyright © 2015 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Background: Depression and pain may sometimes be related conditions. Occasionally, depression may be associated with physical symptoms, such as back pain and headache. Moreover, depression may impair the subjective response to pain and is likely to influence the pain feeling. Conversely, chronic pain may represent an emotional condition as well as physical sensation, and can influence both the mood and behaviour., Aim: To better understand the relationship between pain and depression, we therefore assessed the pain threshold and the tolerance pain threshold in patients with depressive disorders., Materials and Methods: We conducted a case-control study and selected patients who had recently received a diagnosis of major depression (DSM-IV), before treatment, and without any significant pain complaints. Age- and sex-matched healthy controls were also included. Tactile and pain thresholds were assessed in all subjects through an electrical stimulation test. All results were compared between the groups., Results: 27 patients and 27 age-matched healthy controls were included in the study. Tactile, pain and tolerance thresholds were evaluated in all subjects. The pain threshold and pain tolerance were lower in patients with major depression than controls. All differences were statistically significant (p<0.05)., Conclusion: These results suggest the abnormal processing of pain stimuli in depressive disorders., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: Electrical and magnetic trans-spinal stimulation can be used to increase the motor output of multiple spinal segments and modulate cortico-spinal excitability. The application of direct current through the scalp as well as repetitive transcranial magnetic stimulation are known to influence brain excitability, and hence can also modulate other central nervous system structures, including spinal cord., Objective: This study aimed to evaluate the effects and the therapeutic usefulness of these noninvasive neuromodulatory techniques in healthy subjects and in the neurorehabilitation of patients with spinal cord disorders, as well as to discuss the possible mechanisms of action. A comprehensive review that summarizes previous studies using noninvasive spinal cord stimulation is lacking., Methods: PubMed (MEDLINE) and EMBASE were systematically searched to identify the most relevant published studies. We performed here an extensive review in this field., Results: By decreasing the spinal reflex excitability, electrical and magnetic trans-spinal stimulation could be helpful in normalizing reflex hyperexcitability and treating hypertonia in subjects with lesions to upper motor neurons. Transcutaneous spinal direct current stimulation, based on applying direct current through the skin, influences the ascending and descending spinal pathways as well as spinal reflex excitability, and there is increasing evidence that it also can induce prolonged functional neuroplastic changes. When delivered repetitively, magnetic stimulation could also modulate spinal cord functions; however, at present only a few studies have documented spastic-reducing effects induced by repetitive spinal magnetic stimulation. Moreover, paired peripheral and transcranial stimulation can be used to target the spinal cord and may have potential for neuromodulation in spinal cord-injured subjects., Conclusions: Noninvasive electrical and magnetic spinal stimulation may provide reliable means to characterize important neurophysiologic and pathophysiologic aspects of spinal cord function. Moreover, transcutaneous direct current stimulation and repetitive magnetic stimulation may hold therapeutic promise in patients with spinal cord disorders, although future well-controlled studies are needed to corroborate and extend the preliminary findings., (© 2015 International Neuromodulation Society.)

Objective: After spinal cord injury (SCI) reorganization of spinal cord circuits occur both above and below the spinal lesion. These functional changes can be determined by assessing electrophysiological recording. We aimed at investigating the trigemino-cervical reflex (TCR) and trigemino-spinal reflex (TSR) responses after traumatic SCI., Methods: TCR and TSR were registered after stimulation of the infraorbital nerve from the sternocleidomastoid, splenius, deltoid, biceps and first dorsal interosseous muscles in 10 healthy subjects and 10 subjects with incomplete cervical SCI., Results: In the control subjects reflex responses were registered from the sternocleidomastoid, and splenium muscles, while no responses were obtained from upper limb muscles. In contrast, smaller but clear short latency EMG potentials were recorded from deltoid and biceps muscles in about half of the SCI patients. Moreover, the amplitudes of the EMG responses in the neck muscles were significantly higher in patients than in control subjects., Conclusion: The reflex responses are likely to propagate up the brainstem and down the spinal cord along the reticulospinal tracts and the propriospinal system. Despite the loss of corticospinal axons, synaptic plasticity in pre-existing pathways and/or formation of new circuits through sprouting processes above the injury site may contribute to the findings of this preliminary study and may be involved in the functional recovery., Significance: Trigemino-cervical-spinal reflexes can be used to demonstrate and quantify plastic changes at brainstem and cervical level following SCI., (Copyright © 2014 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)

Rapid eye movement (REM) sleep behavior disorder (RBD) is a clinical condition characterized by an intermittent or complete loss of muscle atonia and an increase of phasic muscular activity during REM sleep (or Stage R), leading to complex nocturnal motor behaviors. Correct and early diagnosis is important because RBD may lead to serious injuries and is a well-treatable disorder. Since the characteristic electrophysiologic finding in patients with RBD is the increased electromyographic tone during REM sleep/Stage R, simultaneous video/polysomnography recording is essential for diagnosing this parasomnia. Moreover, several neurophysiological techniques have been used to improve our knowledge and understanding of this troubling sleep disorder. We reviewed the most important studies employing quantitative electroencephalography, event-related potentials, transcranial magnetic stimulation, brainstem reflexes and cortico-muscular coherence analysis. All these neurophysiological techniques have proven to provide a valuable tool to gain insight into the pathophysiological mechanisms underlying RBD. The review concludes with a brief discussion on the possible future implications for improving therapeutic approaches., (Copyright © 2013 Elsevier Ireland Ltd and the Japan Neuroscience Society. All rights reserved.)

Purpose: Urinary incontinence may occur both in epileptic seizures (ES) and in non-epileptic events (NEE) such as psychogenic nonepileptic events (PNEEs) and syncope. A comprehensive search of the literature to determine the accuracy of this physical finding and its prevalence in epileptic seizures and syncope is still lacking. To undertake a systematic review to determine sensitivity, specificity and likelihood ratios (LR) of urinary incontinence in the differential diagnosis between ES and NEEs (including syncope and PNEEs)., Methods: Studies evaluating the presence of urinary incontinence in ES and NEEs were systematically searched. Sensitivity, specificity, positive and negative likelihood ratio (pLR, nLR) of incontinence were determined for each study and for the pooled results., Results: Five studies (221 epilepsy patients and 252 subjects with NEEs) were included. Pooled accuracy measures of urinary incontinence (ES versus NEEs) were: sensitivity 38%, specificity 57%, pLR 0.879 (95% CI 0.705-1.095) and nLR 1.092 (95% CI 0.941-1.268). For each comparison (epileptic seizures versus NEEs; ES versus syncope; ES versus PNEEs), pooled accuracy measures for urinary incontinence showed a statistically not significant pLR (the 95% CI of the pooled value included 1, and the LR value of 1 has no discriminatory value)., Conclusions: A pooled analysis of data from the literature shows that urinary incontinence has no value either in the differential diagnostic between ES and syncope/PNEEs. Systematic reviews with pooled analyses of data from the literature allow an increase in statistical power and an improvement in precision, representing a useful tool to determine the accuracy of a certain physical finding in the differential diagnosis between ES and other paroxysmal events., (Copyright © 2012 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Fixation-off sensitivity (FOS) is a phenomenon induced by elimination of central vision/fixation, and may either manifest clinically with seizures or only represent an EEG abnormality. FOS is characterized by posterior or generalized epileptiform discharges that consistently occur after closing of the eyes and last as long as the eyes are closed. It is most commonly encountered in patients with idiopathic childhood occipital epilepsies, but may also be observed in cases of symptomatic or cryptogenic focal and generalized epilepsies, as well as in asymptomatic non-epileptic individuals. FOS should be differentiated from pure forms of scotosensitivity, in which EEG discharges or epileptic seizures are elicited by darkness, and from epileptiform discharges triggered by eye closure, which refer to eye closure sensitivity. Although FOS is probably associated with occipital hyperexcitability its intrinsic epileptogenic potential is presumed to be low., (Copyright © 2012 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)

Acute and chronic consumption of alcohol have direct effects on central nervous system by altering predominantly gamma-aminobutyric acidergic and glutamatergic neurotransmission. Abnormalities in these neurotransmitter systems can be demonstrated by changes in cortical excitability parameters assessed with transcranial magnetic stimulation (TMS). Furthermore, integrated approaches utilizing TMS combined with electroencephalography (EEG) enable the evaluation of the focal effects of alcohol on the human cortex, providing useful information, different from that obtained using other functional brain imaging modalities. Alcohol was found to modulate EEG responses evoked by motor-cortex TMS, predominantly at the right prefrontal cortex, indicating that ethanol alters the functional connectivity between motor and prefrontal areas. Alcohol decreases amplitudes of EEG responses of anterior parts of the cortex after left prefrontal TMS, suggesting a decrease of prefrontal cortical excitability. High-frequency repetitive TMS (rTMS) revealed significant changes in short-term plasticity of the primary motor cortex after acute ethanol intake and in patients with chronic alcohol abuse. TMS findings also support the recently emerged theory that abnormal function of glutamate receptors plays a relevant role in the development of alcohol dependence and manifestation of the alcohol withdrawal syndrome. Finally, initial studies provide evidence that non-invasive brain stimulation techniques (rTMS and transcranial direct current stimulation) might represent a potential therapeutic tool to reduce alcohol craving. Future studies with larger sample size evaluating the clinical effects of these neuromodulatory approaches are required to confirm and extend the preliminary findings., (Copyright © 2012 Elsevier Ireland Ltd and the Japan Neuroscience Society. All rights reserved.)

Background: Tongue biting (TB) may occur both in epileptic seizures and in syncope. A comprehensive search of the literature to determine the accuracy of this physical finding and its prevalence in epileptic seizures and syncope is still lacking., Aims: To undertake a systematic review and a meta-analysis of studies evaluating the prevalence of TB in patients with epileptic seizures and syncope, and to determine sensitivity, specificity and likelihood ratios (LR) of this physical finding., Method: Studies comparing the prevalence of TB in epileptic seizures and syncope were systematically searched. Prevalence of TB was analyzed calculating odds ratio (OR) with 95% confidence intervals (CIs). Sensitivity, specificity, positive and negative likelihood ratio (pLR, nLR) of TB were determined for each study and for the pooled results., Results: Two studies (75 epilepsy patients and 98 subjects with syncope) were included. There was a significantly higher prevalence of TB in patients with epileptic seizures (OR 12.26; 95% CI 3.99-37.69). Pooled accuracy measures of TB for the diagnosis of epileptic seizures were: sensitivity 33%, specificity 96%, pLR 8.167 (95% CI 2.969-22.461) and nLR 0.695 (95% CI 0.589-0.82)., Conclusions: A pooled analysis of data from the literature shows that TB has great value in the differential diagnosis between epileptic seizures and syncope. Given a certain pre-test probability of seizures, the presence of TB greatly increases the chance that the patient had an epileptic seizure. Systematic reviews with pooled analyses (meta-analyses) of data from the literature allow an increase in statistical power and an improvement in precision, representing a useful tool to determine the accuracy of a certain physical finding in the differential diagnosis between seizures and other paroxysmal events., (Copyright © 2012 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Electroencephalography (EEG) recordings obtained after craniotomy are difficult to interpret because of the presence of a breach rhythm (BR) consisting of unfiltered high-voltage physiological waveforms, sometimes with a spiky and irregular morphology, that can mimic interictal epileptiform abnormalities and may therefore lead to misinterpretations. In this article, we review EEG features of BR and give some technical tips to properly interpret BR and to make a correct differential diagnosis with epileptiform abnormalities. As BR itself has no relationship to epilepsy, it is very important to adopt a "conservative" reading, having a high threshold to call epileptiform abnormalities., (Copyright © 2011 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)