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AIM Psychogenic nonepileptic seizures (PNES) or functional seizures are universal phenomena. However, data on their epidemiology is limited. The aim of the current study was to review the literature on the epidemiology of PNES and to provide analytical estimates of its incidence and prevalence based on the direct data that are available from previous studies on PNES. METHODS The methods of this work had two parts: (1) MEDLINE, PsycINFO, and Scopus from inception to 19 October 2019 were systematically searched. (2) The analytical study of the incidence and prevalence of PNES was performed, based on the following data from previous studies: incidence of PNES, duration of PNES before making a diagnosis, outcome and mortality of PNES. RESULTS The search strategy yielded five articles; three were on the incidence and two on the prevalence. In the analytical part of the study, the incidence of PNES was calculated to be 3.1 (95% Confidence Interval: 1.1-5.1) per 100,000 population per year. The calculated prevalence rate of PNES in 2019 was 108.5 (95% Confidence Interval: 39.2-177.8) per 100,000 population, in the USA. CONCLUSION While, the generalizability of these calculated incidence and prevalence rates to other places in the world is limited, they give us a reasonable hint that PNES is a common condition and the prevalence is much more than that it was thought before.Supplemental data for this article is available online at https://doi.org/10.1080/00207454.2021.1942870.

The aim of this systematic review was to provide the required information regarding different aspects of the relationship between epilepsy/antiseizure medications and non-alcoholic drinks. The recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement were followed. MEDLINE and Scopus from the inception until 7 August 2021 were systematically searched. These key words were used: "epilepsy" OR "seizure" OR "antiepileptic" OR "antiseizure" OR "anticonvulsant" AND "coffee" OR "tea" OR "soda" OR "juice" OR "drink" OR "cola" OR "diet" (35 key word combinations). The primary search yielded 21 458 publications (PubMed, n = 4778; Scopus, n = 16 680). Only 50 studies met all the inclusion criteria and were included in the current systematic review. In total, 17 articles investigated various non-alcoholic drinks in human studies, 11 studies were case reports/series, and 22 articles were animal/in vitro studies. None of the studies provided a class 1 of evidence. There is limited evidence suggesting that certain drinks (eg, caffeinated energy drinks) might trigger seizures. Patients with epilepsy should avoid excessive consumption of certain fruit juices (eg, grapefruit, lime, pomegranate, kinnow, and star fruit) and caffeinated drinks. However, daily coffee and tea intake can be part of a healthy balanced diet, and their consumption does not need to be stopped in patients with epilepsy. Coffee/tea consumption is not harmful if consumed at levels of 200 mg (caffeine) in one sitting (about 2½ cups of coffee) or 400 mg daily (about five cups of coffee).

The coronavirus disease 2019 (COVID‐19) pandemic has affected the care of all patients around the world. The International League Against Epilepsy (ILAE) COVID‐19 and Telemedicine Task Forces examined, through surveys to people with epilepsy (PWE), caregivers, and health care professionals, how the pandemic has affected the well‐being, care, and services for PWE. The ILAE included a link on their website whereby PWE and/or their caregivers could fill out a survey (in 11 languages) about the impact of the COVID‐19 pandemic, including access to health services and impact on mental health, including the 6‐item Kessler Psychological Distress Scale. An anonymous link was also provided whereby health care providers could report cases of new‐onset seizures or an exacerbation of seizures in the context of COVID‐19. Finally, a separate questionnaire aimed at exploring the utilization of telehealth by health care professionals since the pandemic began was available on the ILAE website and also disseminated to its members. Seventeen case reports were received; data were limited and therefore no firm conclusions could be drawn. Of 590 respondents to the well‐being survey (422 PWE, 166 caregivers), 22.8% PWE and 27.5% caregivers reported an increase in seizure frequency, with difficulty in accessing medication and health care professionals reported as barriers to care. Of all respondents, 57.1% PWE and 21.5% caregivers had severe psychological distress (k score >13), which was significantly higher among PWE than caregivers (p

Purpose The aim of the current study was to investigate the risk factors for post-traumatic epilepsy (PTE) in a large cohort of patients after severe non-penetrating civilian traumatic brain injury (TBI). Methods This was a longitudinal study. All patients with a severe non-penetrating TBI, who were admitted at the neuro-intensive care unit of Shahid Rajaee Trauma Hospital, affiliated with Shiraz University of Medical Sciences, Shiraz, Iran, from 2015 until 2019, were studied. Severe TBI was defined as a Glasgow Coma Scale-Motor score below six. Post-traumatic epilepsy was defined as any seizures that occurred after being discharged from the hospital. Results In total, 803 patients with severe non-penetrating TBI were studied; 82 patients (10.2%) reported any late post-traumatic seizures (PTSs). A higher Glasgow outcome scale (extended) at discharge was significantly inversely associated with PTE [Odds Ratio (OR)= 0.76, 95% Confidence Interval (CI): 0.65–0.87; p = 0.0001]. Depressed skull fracture (OR= 1.88, 95% CI: 0.92–3.80; p = 0.081), epi‑dural hematoma (OR= 1.67, 95% CI: 0.93–2.97; p = 0.083), and sub-dural hematoma (OR= 1.64, 95% CI: 0.96–2.78; p = 0.068) were associated with PTE as trends. Conclusion Our study adds to the literature on the risk of PTE after severe non-penetrating civilian TBI. Our large sample size and also the application of a logistic regression analysis model may suggest that other variables (e.g., depressed skull fracture and intracranial hematoma) are indeed associated with the Glasgow outcome scale (extended) at discharge and that is why they lost their significance in the model.

Introduction: Despite more than one year passed since the first cases of SARS-CoV-2 were reported, there is still no consensus on the definition and clinical management of post-acute-COVID-19. The condition has heterogeneously been named as Chronic COVID syndrome, Post COVID-19 Syndrome, post-acute sequela of SARS-CoV-2 (PASC), and the more familiar long COVID. Method: In order to capture all relevant published studies, we undertook a multi-step search with no language restriction. The following four-step search strategy was utilized: First, a preliminary (limited) search was conducted on January 20, 2021, in Google Scholar and PubMed to identify the appropriate keywords. Then, on January 30, 2021, we adopted a search strategy of electronic databases from Cochrane Library, PsycINFO, PubMed, Embase, Scopus, and Web of sciences, using those keywords. Then, after duplicate removal, we screened all titles, abstracts, and full texts. This resulted in 66 eligible studies. Subsequently, after a forward and backward search of their references and citations an additional 54 publications were found, resulting in a total of 120 publications that formed the basis of the present analysis. The titles, abstracts, and full-texts of non-English articles were translated using Google Translate for further evaluation. We conducted our scoping review based on the PRISMA-ScR Checklist.Results: We found only one randomized clinical trial in our search. Of the 67 original studies, 22 were cohort and 28 were cross-sectional studies totaling 74.6% of the original studies. Of the total of 120 publications, 59 (49.1%) focused on signs and symptoms, 28 (23.3%) were focused on management, and 13 (10.8%) focused on pathophysiology. Ten (9%) publications focused on imaging studies. Ninety-one percent of the original investigations came from high and upper-middle-income countries, highlighting the scarcity of reports originating from low-income and lower-middle-income countries.Conclusion: The predominant symptoms among those with the so-called “Long COVID” were: fatigue, breathlessness, arthralgia, sleep difficulties, and chest pain. Recent reports also point to the risk of long-term sequela with cutaneous, respiratory, cardiovascular, musculoskeletal, mental health, neurologic, and renal involvement in those who survive the acute phase of the illness. The ambiguity and controversies in its definition have impaired proper recognition and management of those requiring additional support following the resolution of the acute phase of this infection. This has resulted in long-standing distress for the patients and their families. Our findings highlight the need for a multidisciplinary approach, support, and rehabilitation for these patients in terms of long-term mental and physical health.

We systematically reviewed the existing literature on the safety of the use of smartphone, mobile phone/Internet, and Wi-Fi by people with epilepsy (PWE), according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Scopus, MEDLINE, and Google Scholar from the inception to April 9, 2021 were searched. These key words were used "epilepsy" OR "seizure" AND "Mobile Phone" OR "Cell Phone" OR "Smartphone" OR "Wi-Fi" OR "Electromagnetic" OR "Radiation." The primary search yielded 7766 studies; 33 studies were related. In total, 19 manuscripts were based on animal/computational studies and 14 articles reported human investigations. Among animal studies, 10 articles suggested detrimental effects by electromagnetic fields (EMFs) on brain function/seizure activity, while nine studies negated this hypothesis. Among human studies, seven studies suggested detrimental effects by EMFs on brain function/seizure activity, while seven studies negated this hypothesis. None of the studies provided a good level of evidence. In one human study, all seven patients with epilepsy and abnormal EEG during the sham exposure, had an increase in the number of epileptic events with exposure to mobile phone radiation. In another study of the detrimental effects of smart technology device overuse among school students, an association was found between reporting seizures and the hours of smart technology device use. While high-quality evidence on the safety of the use of smartphone, mobile phone/Internet, and Wi-Fi in PWE is lacking, prudent use of these technologies, including using wired hand-free sets or other exposure-reducing measures is recommended.

Objective. The aim of the current study was to investigate the opinions of neurologists and psychiatrists in Iran on the necessity of COVID‐19 vaccination in patients with epilepsy (PWE). These data can help policy makers understand the concerns of these healthcare professionals. Methods. This was a survey study. On September 1st, 2020 we sent a questionnaire (using Google‐forms) to all neurologists and psychiatrists in Iran via WhatsApp. The survey included three general questions (age, sex, and discipline) and six COVID‐specific questions. Results. In total, 202 physicians participated in this study (116 neurologists and 86 psychiatrists). Of the participants, 27% believed that PWE are at increased risk of contracting COVID‐19. The majority (74%) of the participants would confidently recommend COVID‐19 vaccine to their patients. However, only 49% of the physicians would recommend such a vaccine to all patients; others would consider it in special populations only. The overwhelming majority (91%) of the participants would recommend COVID‐19 vaccine only when a reliable vaccine becomes available. Many physicians would trust a vaccine that is approved by the World Health Organization (WHO) (46%) or a vaccine that is approved by the Food and Drug Administration (FDA‐USA) (34%). Significance. Physicians have concerns on the issue of the necessity of (a future) COVID‐19 vaccine in PWE. The most important concern is the reliability of a vaccine and in this regard, two health agencies, the WHO and the FDA, are the most trusted organizations to approve a vaccine against COVID‐19.

Summary Objective The purpose of the current study was to systematically review the literature on the clinical trials of vitamin-mineral supplementations in people with epilepsy (PWE) to treat their seizures. Methods MEDLINE and Scopus from inception to August 25, 2020 were searched for related published manuscripts. The search keywords included “vitamin or folate or folic acid or biotin or thiamine or carnitine or zinc or manganese or selenium or omega-3 fatty acid or linoleic acid or micronutrient or trace element or supplementation” AND “epilepsy or seizure”. Results We could identify 26 related articles. Seventeen studies provided class 2 of evidence and the rest provided class 3 of evidence. Eight studies investigated polyunsaturated fats, seven groups studied folic acid, four studies explored the effects of vitamin D, two investigated vitamin E, and three others studied multivitamin cocktails. There was one study on zinc and one on selenium. There is some evidence on the efficacy of polyunsaturated fats in treating seizures in PWE. The evidence on the efficacy of multivitamin cocktails in adults is promising. Conclusion High quality data on the efficacy of nutritional (vitamins-minerals) supplementations in treating seizures in PWE is scarce; however, designing future clinical trials of polyunsaturated fatty acid supplementation for drug-resistant seizures in adults with focal epilepsy and in children, and also multivitamin supplementations in adults with focal epilepsy seems reasonable and promising. Such clinical trials should be well-designed, randomized, and placebo controlled, with enough sample size and adequate follow-up of 12 months or more.

Objective To determine whether patients with epilepsy (PWE) are particularly over-represented in a very large cohort of patients with COVID-19. We also investigated whether COVID-19 is associated with a different clinical picture or a more severe course of illness in PWE (compared with others). Methods All consecutive patients who referred to and admitted at healthcare facilities anywhere in Fars province (located in the south of Iran with a population of 4,851,000 people) from February 19, 2020 until November 20, 2020 were included. Results A total of 37,968 patients were studied. Eighty-two patients (0.2%) had pre-existing epilepsy. Seizures were significantly more frequent among PWE as a presenting manifestation of COVID-19 compared with that in people without epilepsy (Odds Ratio = 27; p = 0.0001). Furthermore, PWE less often reported cough (significantly) and more often had gastrointestinal symptoms (vomiting and anorexia; as trends) compared with those in people without epilepsy. Patients with epilepsy were not differently likely to be intubated or admitted at ICUs. Case fatality rates were not different between the two groups [9.8% in PWE and 8.5% in people without epilepsy; p = 0.690]. Conclusion Patients with epilepsy are not susceptible to contracting COVID-19 more than other individuals. Furthermore, COVID-19 in PWE is not associated with a more severe illness or a poorer prognosis. However, PWE and COVID-19 may present somewhat differently than others with such an illness. Why PWE less often present with cough and more often present with gastrointestinal symptoms is not clear yet and should be investigated and clarified in the future studies.

PURPOSE OF REVIEW We review data on injuries and traffic accidents affecting people with epilepsy with emphasis on the overall risk of injuries, specific types of injuries, and risk factors. RECENT FINDINGS Population-based studies of incident epilepsy cohorts indicate that the risk of physical injuries in people with epilepsy in general is increased only modestly. The risk is higher in selected populations that attend epilepsy clinics or referral centers. Soft tissue injuries, dislocations, and fractures are the most common injures, whereas the greatest increase in risk is reported for more uncommon injuries such as drowning. People with epilepsy are at a two-fold to four-fold increased risk for fatal injuries. Comorbidities contribute to fatal as well as nonfatal injuries. The other major risk factor is poorly controlled major convulsive seizures (generalized as well as focal to bilateral tonic-clonic seizures). Serious transport accidents associated with increased risks for people with epilepsy include pedestrian, bicycle, as well as car accidents. SUMMARY Individualized information on the risk of physical injuries and accidents should be part of counseling of patients with epilepsy. Improved seizure control is likely the most effective way to reduce risks, but work place and home adjustments should also be considered.

OBJECTIVE: Optimal choice of antiseizure medication (ASM) depends on seizure type, syndrome, age, gender, comorbidities and co-medications. There are no fixed rules on how to weigh these factors; choices are subjective and experience-driven. We investigated agreement among experts in selecting ASM as monotherapy and used their prevailing choices to validate a web-based decision-support application.METHODS: Twenty-four international experts, blinded to the app, selected the optimal ASM for 25 individual patient-cases covering a wide variation of seizure types and other factors influencing ASM selection. The app ranked ASMs in order of likely appropriateness for each case. In a second step, experts rated anonymously the choices of the app.RESULTS: Of the 25 patient-cases (age 13-74 years), 13 were female, 18 (72%) had comorbidities, six (24%) were on contraceptives, and 13 (52%) had other co-medications. The median number of experts who selected the same ASM for a given case was 15 (62.5%) and interquartile range (IQR) 13-18 (54%-75%). Gwet's agreement coefficient among experts was 0.38 (95% confidence interval [CI] 0.32-0.44), corresponding to a "fair" agreement. Agreement between the app and the prevailing expert choice for each case was 0.48 (95% CI 0.29-0.67), corresponding to a "moderate" beyond chance agreement. The percent agreement between the highest ranked selections of the app and the expert selections was 73% (95% CI 64%-82%). Ninety-five percent of the experts considered that no incorrect or potentially harmful ASMs were ranked highest by the app, and most experts strongly agreed with the app's selections.SIGNIFICANCE: This app, now validated by experts, provides an objective, reproducible method for selecting ASM that accounts for relevant clinical features. It is freely available at: https://epipick.org.

We compared the demographic, clinical, and electroencephalographic (EEG) characteristics between females and males with idiopathic generalized epilepsy (IGE). In this retrospective study, all patients with a clinical diagnosis of IGE were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, from 2008 through 2019. Age, gender, age at seizure onset, seizure type(s), epilepsy risk factors, and EEG findings of all patients were registered routinely. Six hundred one patients with IGE were studied: 361 patients (60%) were females, and 240 people (40%) were males. The mean age at onset of seizures was 1.3 years earlier in males compared with that in females. Myoclonic seizures were more frequently reported by females than that by males. Photoparoxysmal response during intermittent photic stimulation in the EEG laboratory was more often observed in females than that in males. The difference in the syndromic diagnosis between the sexes was significant (p = 0.02). Among male patients, 88% were on valproate, and among female patients, 49% were on valproate (p = 0.0001). At the last follow-up visit, 83 males (61%) and 108 females (49%) were seizure-free (p = 0.02). There are significant demographic, clinical, and electrographic differences between females and males with IGEs. The reasons behind these sex differences among patients with IGE are not clear. However, it is likely that sex hormones and sex chromosome genes-related brain differences play a role in the development of these differences. These interesting findings and the proposed hypothesis should be explored in future studies.

Objective The purpose of the current study was to collect the data on the occurrence of seizures in patients with COVID-19 and to clarify the circumstances of the occurrence of seizures in these patients. Methods All consecutive patients who referred to healthcare facilities anywhere in Fars province (located in South Iran with a population of 4.851 million people) from February 19 until June 2, 2020, and had confirmed COVID-19 by positive result on polymerase chain reaction testing and seizure were included. Results During the study period, 6,147 people had confirmed COVID-19 in Fars province, Iran; 110 people died from the illness (case fatality rate 1.79%). During this time period, five people had seizures (seizure rate 0.08%). In four patients, seizure was one of the presenting manifestations, and in one person, it happened during the course of hospital admission. Two patients had status epilepticus. All patients experienced hypoxemia and four of them needed respirator. Two patients had related metabolic derangements and one had cerebrospinal fluid (CSF) lymphocytic pleocytosis. Brain imaging was abnormal in three patients. Four patients died. Conclusion New-onset seizures in critically ill patients with COVID-19 should be considered as acute symptomatic seizures and the treating physician should try to determine the etiology of the seizure and manage the cause immediately and appropriately. Detailed clinical, neurological, imaging, and electrophysiological investigations and attempts to isolate SARS-CoV-2 from CSF may clarify the role played by this virus in causing seizures in these patients. Electronic supplementary material The online version of this article (10.1007/s10072-020-04731-9) contains supplementary material, which is available to authorized users.

Objectives We surveyed people with epilepsy (PWE) and uncontrolled seizures on the challenges which they have had in their lives with respect to educational achievement, employment, and marriage. We tried to scrutinize their reasons and perceptions for their social underachievement and difficulties. Materials and Methods Adult patients above 25 years of age, with epileptic seizures for more than 5 years, who were investigated at Shiraz Comprehensive Epilepsy Center, from January until March 2019, were studied. We prepared a questionnaire for our study and asked whether they have any college education? If they have ever married? And, if they are employed? Results Seventy patients enrolled in our study. Age of the patients was 33 ± 6 years (range: 26–59 years) and their age at onset of epilepsy was 14 ± 9 years (range: 0–35 years). Forty-four patients (63%) never received any college education; 30 patients (43%) were single; and finally, 37 patients (53%) were unemployed. The most common reasons perceived by the patients for these life challenges were functional disability (e.g., inability to study or to work), social discrimination and stigmatization, and uncontrolled seizures and the associated consequences (i.e., fear of having seizures). Conclusion Many PWE (both men and women) and uncontrolled seizures suffer from social underachievement and challenges in their daily lives. Various strategies may help PWE to overcome these challenges.

Objective To investigate the effects of COVID‐19 pandemic on patients’ perceptions of hardship in obtaining their drugs and if this pandemic and the social restrictions in response to that has resulted in any changes in their seizure control status. We also investigated factors potentially associated with the perceptions of difficulty in obtaining their drugs (e.g., polytherapy vs. monotherapy, taking imported drugs, and seizure status worsening). Methods We surveyed a random sample of patients with epilepsy, who were registered in our database at Shiraz Epilepsy Center, Iran, on their perceptions on two issues: What has been your experience on obtaining your antiseizure medications in the past four weeks (compared to before)?Have you experienced any changes in your seizure control status in the past four weeks? Results We included 100 patients (53 male and 47 female patients). In response to the question “Have you had any difficulties in the past 4 weeks to obtain your drugs?”, 31 people (31%) expressed hardship obtaining their drugs. In response to the question “How has been your seizure control status compared with before?”, six people (6%) expressed worsening of their seizure control status in the past 4 weeks. None of the patients reported symptoms of coronavirus infection. Conclusion About one‐third of patients with epilepsy expressed significant hardship obtaining their drugs after the intensification of the COVID‐19 outbreak in Iran. The current COVID‐19 pandemic could be considered as a major shock to a nation that has already been under significant pressure (i.e., Iran).

Although antiepileptic drugs (AEDs) are mainstay of the treatment of epilepsy, they are associated with significant adverse effects. The present study reviews the adverse effects of AEDs on some of the nutrition-related issues, including bone health, body weight, glucose and lipid metabolism, vitamin homeostasis, antioxidant defense system, and pregnancy. This paper also provides some nutritional recommendations for people with epilepsy. Patients with epilepsy should be regularly evaluated with regard to their nutrition status and any possible nutritional problems. Daily intake of adequate amounts of all nutrients from various sources should be encouraged, especially for vulnerable groups such as children, adolescents, elderly, and pregnant women. When necessary, preventative or therapeutic supplementation with appropriate micronutrients could be helpful. Graphical abstract.

Highlights • Seizures have been reported in patients with various coronavirus infections. • However, seizures seem to be a rare occurrence in people with COVID-19. • Patients with COVID-19 may have hypoxia, multiorgan failure, and metabolic disarrangements. • It is plausible to expect acute symptomatic seizures to happen in these patients. • One should be prepared to treat seizures appropriately., Neurotropic and neuroinvasive capabilities of coronaviruses have been described in humans. Neurological problems found in patients with coronavirus infection include: febrile seizures, convulsions, loss of consciousness, encephalomyelitis, and encephalitis. Coronavirus disease (COVID-19) is caused by SARS-COV2. In severe cases, patients may develop severe pneumonia, acute respiratory distress syndrome, and acute cardiac injury. While seizures and status epilepticus have not been widely reported in the past five months since the onset of COVID-19 pandemic, patients with COVID-19 may have hypoxia, multiorgan failure, and severe metabolic and electrolyte disarrangements; hence, it is plausible to expect clinical or subclinical acute symptomatic seizures to happen in these patients. One should be prepared to treat seizures appropriately, if they happen in a patient who is already in a critical medical condition and suffers from organ failure.

We compared various syndromes of idiopathic (genetic) generalized epilepsy (IGE) with absences based on their demographic, clinical, and electroencephalographic (EEG) findings, and their seizure outcome. In this retrospective study, all patients with a clinical diagnosis of childhood absence epilepsy (CAE), juvenile absence epilepsy (JAE), idiopathic epilepsy with phantom absences (PAs), and Jeavons syndrome (JS) were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, from 2008 until 2019. Age, gender, age at seizure onset, seizure type(s), epilepsy risk factors, history of seizure-related injuries, EEG findings, and seizure outcome of all patients were registered routinely. Six hundred one patients with IGE were registered at our epilepsy clinic. Two hundred thirteen patients (35.4%) were diagnosed as having IGE with absences [111 patients (52.1%) had JAE, 82 patients (38.5%) had CAE, 12 people (5.6%) had JS, and eight patients (3.8%) had PA]. A history of experiencing generalized tonic-clonic seizures and a history of seizure-related injury were significantly different between the syndromes. There were no significant differences between the syndromes with regard to their EEG findings. Seizure outcome showed a trend to be different between the syndromes of IGE (p = 0.06). Syndromes of IGE with absences are common occurrences at epilepsy clinics. Making a syndromic diagnosis could have significant clinical implications. In doing so, interictal EEG cannot differentiate between different syndromes of IGE and the key element in making a correct syndromic diagnosis is a detailed clinical history.

We investigated medical comorbidities in patients with psychogenic non-epileptic seizures (PNES). We hypothesized that these patients commonly have significant medical comorbidities. In this retrospective study, all patients with PNES, who were diagnosed at Shiraz Comprehensive Epilepsy Center, Iran, from 2008 until 2019, were investigated. Age, gender, age at seizure onset, seizure semiology, and characteristics, known medical (organic) comorbidities reported by the patients and video-electroencephalography recordings of all patients were registered routinely. During the study period, 272 patients with PNES-only had the inclusion criteria and were studied. Sixty-five patients (24%) reported having a medical (organic) comorbidity. The most commonly reported medical comorbidity was thyroid disorder. Age at onset (OR: 1.058; 95% CI: 1.026–1.090; p = 0.0001), duration of disease before the diagnosis (OR: 1.071; 95% CI: 1.025–1.119; p = 0.002), and sex (female) (OR: 1.97; 95% CI: 1.016–3.834; p = 0.04) were significantly associated with having medical comorbidities. While we did not have a control group to provide the number and type of medical problems that are expected in the general population, and therefore our results should be interpreted with caution, we had some intriguing observations. About one quarter of patients with PNES reported having medical comorbidities. The exact nature of the relationship between medical illnesses and PNES is not clear; however, hypothetically they could have a complex relationship. This study provides valuable information on the frequency and nature of medical comorbidities in patients with PNES and opens new horizons for future research.

Purpose We investigated the prevalence of generalized tonic-clonic seizures (GTCSs) in patients with idiopathic generalized epilepsy (IGE) and the risk factors associated with them. We also studied the seizure outcome in patients with IGEs. Methods In this retrospective study, all patients with a diagnosis of IGE were recruited at the epilepsy clinic at Shiraz University of Medical Sciences, from 2008 through 2019. Age, gender, age at seizure onset, seizure type(s), EEG findings, and seizure outcome of all patients were registered. Results A total of 601 patients with IGE were studied; 516 patients (86%) had GTCSs. The ROC curve showed that reporting GTCSs was significantly associated with the time since the start of the disease (P = .0001; area under the curve = 0.71 [95% CI: 0.66-0.76]; a cutoff point of 4 years [sensitivity = 61% and specificity = 76%]). Age at onset was 3.3 years later in patients with GTCSs compared with that in patients without GTCSs. Generalized spike-wave complexes during interictal EEG recording were more frequently observed among patients without GTCSs. Generalized tonic-clonic seizures were significantly associated with experiencing seizure-related injuries. Valproate reduced the risk of experiencing GTCSs significantly (OR: 0.58; 95% CI: 0.34-0.99; P = .04). Conclusion Generalized tonic-clonic seizures do not affect the seizure outcome in patients with IGEs per se, but how we manage them significantly affects the seizure outcome in these patients. Failure to prescribe valproate for women with IGE, particularly when another first-line treatment has failed, may not be in a patient's best interests.

Purpose:The aim of the current study was to investigate the prevalence of face mask wearing among different groups of people in south Iran. We also investigated the associations between mask wearing hesitancy and various factors.Methods:We surveyed a sample (convenience sampling) of 5 groups of people: general population, people with epilepsy, people with diabetes mellitus (DM), people with cardiac problems, and people with psychiatric problems. The survey included 4 general questions (age, sex, education, and medical/psychiatric problem) and 4 coronavirus disease 2019 (COVID-19)-specific questions (contracting COVID-19, relatives with COVID-19, wearing a face mask while in crowded places, and the frequency of daily hand washings).Results:A total of 582 people (153 people with epilepsy, 127 patients with DM, 98 people with cardiac problems, 96 patients with psychiatric disorders, and 108 healthy individuals) participated. Twenty-eight (4.8%) people expressed that they do not wear a face mask when at crowded places. A lower education and less frequent daily hand washings had associations with mask wearing hesitancy.Conclusions:Mask wearing hesitancy is a concern during a respiratory viral disease pandemic. Paying attention to personal variables, especially if they are modifiable (eg, education and hygiene), is probably productive and practical in promoting mask wearing culture.

Objectives:The aim of this study was to investigate the opinions of different groups of people in Iran on their willingness to receive a coronavirus disease 2019 (COVID-19) vaccine.Methods:In this cross-sectional study, we surveyed a sample (based on consecutive referrals) of 5 groups of people in late 2020: a group of the general population from Shiraz (without a history of any chronic medical or psychiatric problems), patients with epilepsy, patients with diabetes mellitus (DM), patients with cardiac problems, and patients with psychiatric problems. The survey included 4 general questions and 3 COVID-19–specific questions.Results:A total of 582 people participated. In total, 66 (11.3%) people expressed that they were not willing to receive a COVID-19 vaccine. Psychiatric disorders (odds ratio [OR]: 3.15; 95% confidence interval [CI]: 1.31-7.60; P = 0.006) and male sex (OR: 2.10; 95% CI: 1.23-3.58; P = 0.010) were significantly associated with COVID-19 vaccine hesitancy.Conclusion:Vaccine hesitancy is a global issue. Patients with psychiatric disorders had the highest rate of vaccine hesitancy. Previous studies have shown that depression and anxiety are associated with a reduced adherence to the recommended medical advice. Why male sex is associated with vaccine hesitancy is not clear. Researchers should investigate the rates and the factors affecting the vaccine hesitancy in their corresponding communities.

Background and purposeAntiseizure medications (ASMs) should be tailored to individual characteristics, including seizure type, age, sex, comorbidities, comedications, drug allergies, and childbearing potential. We previously developed a web-based algorithm for patient-tailored ASM selection to assist health care professionals in prescribing medication using a decision support application (https://epipick.org). In this validation study, we used an independent dataset to assess whether ASMs recommended by the algorithm are associated with better outcomes than ASMs considered less desirable by the algorithm.MethodsFour hundred twenty-five consecutive patients with newly diagnosed epilepsy were followed for at least 1 year after starting an ASM chosen by their physician. Patient characteristics were fed into the algorithm, blinded to the physician's ASM choices and outcome. The algorithm recommended ASMs, ranked in hierarchical groups, with Group 1 ASMs labeled as the best option for that patient. We evaluated retention rates, seizure freedom rates, and adverse effects leading to treatment discontinuation. Survival analysis contrasted outcomes between patients who received favored drugs and those who received lower ranked drugs. Propensity score matching corrected for possible imbalances between the groups.ResultsAntiseizure medications classified by the algorithm as best options had a higher retention rate (79.4% vs. 67.2%, p = 0.005), higher seizure freedom rate (76.0% vs. 61.6%, p = 0.002), and lower rate of discontinuation due to adverse effects (12.0% vs. 29.2%, p < 0.001) than ASMs ranked as less desirable by the algorithm.ConclusionsUse of the freely available decision support system is associated with improved outcomes. This drug selection application can provide valuable assistance to health care professionals prescribing medication for individuals with epilepsy.

Highlights • People with functional seizures often suffer from psychiatric comorbidities. • People with FS report detrimental effects on social aspects of their lives. • FS are associated with a considerable direct and indirect economic burden. • FS have increased rates of mortality compared to healthy controls., Functional seizures (FS) are frequently encountered in neurology clinics, often affect young adults, and have significant negative impacts on many aspects of a person’s life. In the current narrative review, we searched the literature regarding some of the consequences of FS (i.e., psychiatric comorbidities, social consequences, costs that are associated with the condition, cognitive impairment in patients with FS, the quality of life of the people with FS, and the increased risk of mortality that is associated with FS). Evidence shows that FS have significant negative consequences, comparable in their magnitude to those affecting patients with epilepsy. The clinical and scientific communities should take steps to address these consequences through clinical care and research that prioritizes, facilitates, and expedites evidence-based diagnosis and treatment for FS.

We investigated the frequency of brain fog in a large cohort of patients with documented coronavirus disease‐2019 (COVID‐19) who have survived the illness. We also scrutinized the potential risk factors associated with the development of brain fog. Adult patients (18–55 years of age), who were referred to the healthcare facilities anywhere in Fars province from February 19, 2020 to November 20, 2020 were included. All patients had a confirmed COVID‐19 diagnosis. In a phone call, at least 3 months after their discharge from the hospital, we obtained their current information. A questionnaire was specifically designed for data collection. In total, 2696 patients had the inclusion criteria; 1680 (62.3%) people reported long COVID syndrome (LCS). LCS‐associated brain fog was reported by 194 (7.2%) patients. Female sex (odds ratio [OR]: 1.4), respiratory problems at the onset (OR: 1.9), and intensive care unit (ICU) admission (OR: 1.7) were significantly associated with reporting chronic post‐COVID “brain fog” by the patients. In this large population‐based study, we report that chronic post‐COVID “brain fog” has significant associations with sex (female), respiratory symptoms at the onset, and the severity of the illness (ICU admission).

International audience; Video-encephalographic (vEEG) seizure recordings make essential contributions to the differentiation of epilepsy and psychogenic nonepileptic seizures (PNES). The yield of vEEG examinations can be increased through suggestive seizure manipulation (SSM) (ie, activation/provocation/cessation procedures), but its use has raised ethical concerns. In preparation for guidelines on the investigation of patients with PNES, the ILAE PNES Task Force carried out an international survey to investigate practices of and opinions about SSM. An online questionnaire was developed by the ILAE PNES Task Force. Questions were asked at clinical unit or individual respondent level. All ILAE chapters were encouraged to send questionnaires to their members. The survey was open from July 1, 2019, to August 31, 2019. A total of 487 clinicians from 411 units across 94 countries responded. Some form of SSM was used in 296/411 units (72.0%). Over 90% reported the use of verbal suggestion, over 80% the use of activation procedures also capable of eliciting epileptic activity (hyperventilation or photic stimulation). Only 26.3% of units used techniques specifically intended to provoke PNES (eg, saline injection). Fewer than 10% of units had established protocols for SSM, only 20% of units required written patient consent, in 12.2% of units patients received explicitly false information to provoke seizures. Clinicians using SSM tended to perceive no ethical problems, whereas those not using SSM were likely to have ethical concerns about these methods. We conclude that the use of invasive nocebo techniques intended to provoke PNES in diagnostic settings has declined, but SSM is commonly combined with activation procedures also capable of eliciting epileptic activity. While research suggests that openness about the use of PNES-specific nocebo techniques does not reduce diagnostic yield, very few units have suggestion protocols or seek patient consent. This could be addressed through establishing consensus guidance for the practice of SSM.

Purpose We investigated the driving rate and the rate of road traffic accidents in patients with functional seizures. We hypothesized that road traffic accidents are common in these patients. Methods In this long-term study, all patients with functional seizures, who were diagnosed at Shiraz Comprehensive Epilepsy Center, Iran, from 2008 until 2018, were investigated. In a phone call interview in February 2020, we obtained the following information: seizure outcome, driving a motor vehicle, experiencing any road traffic accidents in the past 12 months, and their drug regimen. Results 100 patients participated; 41 patients were driving a motor vehicle in their routine daily lives. Seizure freedom [Odds Ratio (OR): 6.15; 95 % Confidence Interval (CI): 1.95–19.35; p = 0.002] and being employed (OR: 10.66; 95 % CI: 3.03–37.49; p = 0.0001) were significantly associated with driving a motor vehicle. Five patients reported experiencing road traffic accidents while driving a motor vehicle in the past 12 months. All these five patients reported being seizure-free. Conclusion The majority of patients with functional seizures do not drive a motor vehicle; fear of seizures is a significant determinant. When patients with functional seizures achieve seizure freedom, the rate of driving a motor vehicle increases significantly. The rate of road traffic accidents in patients with functional seizures does not seem to be high.

Purpose We investigated the occurrence and clinical characteristics of late-onset idiopathic generalized epilepsies (IGEs). We also provided a statistically meaningful definition for late-onset IGE in this large cohort of patients. Methods In this cross-sectional retrospective chart review study, all patients with a clinical diagnosis of IGE were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences from 2008 until 2019. We defined “late-onset IGE” according to the following equation: those with an age at onset of their seizures above X years [X = mean age at the seizure onset of all patients + 2 × (standard deviation)]. Results During the study period, 601 patients with IGE were registered at our epilepsy clinic. Late-onset IGE was defined as having an age at onset of above 26 years. Fifteen patients (2.5%) had late-onset IGE. The syndromic diagnosis of these patients included: IGE with absences [6 patients (40%)], generalized tonic-clonic only (GTC-only) [5 patients (33.3%)], and juvenile myoclonic epilepsy (JME) [4 patients (26.7%)]. Conclusion While late-onset IGE (IGE with an age at onset of above 26 years) is not common, one should consider the possibility of its occurrence in adults with new-onset seizures. This condition shares many of the clinical and electroencephalograic features of classical IGEs, which supports the hypothesis that IGE syndromes in different age groups share common biological determinants.

We investigated the sex ratio trajectory across the lifespan in patients with psychogenic nonepileptic seizures (PNES). We hypothesized that there are significant changes in the trajectory of the sex ratio in these patients across the lifespan with respect to the age at onset.In this retrospective study, all patients with PNES, who were diagnosed at Shiraz Comprehensive Epilepsy Center, Iran, from 2008 until 2019, were investigated. We arbitrarily categorized the patients into five groups according to the age at onset of their PNES [pre-puberty (≤ 14 years), adolescence (15 years to19 years), young adulthood (19-25 years), adulthood (26-45 years), and post-menopausal (≥ 46 years)].During the study period, 275 patients with PNES-only had the inclusion criteria. The sex ratios (female to male) of the studied groups according to the age at onset of PNES were as follows: pre-puberty (13:14 = 0.93), adolescence (32:21 = 1.52), young adulthood (54:33 = 1.64), adulthood (71:26 = 2.73), and post-menopausal (7:4 = 1.75). In two-by-two comparison of the group with the lowest sex ratio (pre-puberty) and the group with the highest sex ratio (adulthood) the difference was significant (p = 0.01).We postulate that the higher prevalence of PNES in women may be partly associated with lifetime sex hormone fluctuations; this female preponderance appears during puberty and decreases after menopause. However, most likely this is only one of many potential reasons behind this sex difference; therefore, this is an interesting avenue for future studies.

We assessed the relationship between the clinical features of patients with psychogenic nonepileptic seizures (PNES) and referrals for brain imaging tests. We also hypothesized that some clinical factors might be associated with structural brain imaging abnormalities in these patients. In this retrospective study, patients with PNES, who were investigated at Shiraz Comprehensive Epilepsy Center, Iran, from 2008 until 2019, were studied. One hundred thirty-two patients had a brain magnetic resonance imaging (MRI) study available. Forty-seven patients (36%) had abnormal finding(s) in their MRI. Age (odds ratio = 1.040, p = 0.02), and comorbid epilepsy (odds ratio = 3.006, p = 0.005) were significantly associated with having an abnormal brain MRI. In a subanalysis, we excluded the patients with comorbid epilepsy (46 patients). From the remaining 86 patients (with PNES only), 23 patients (26.7%) had abnormal findings on their MRIs. Common epileptogenic structural brain abnormalities (e.g., tumors, mesial temporal sclerosis, encephalomalacia, and developmental anomalies) were common in patients with comorbid PNES and epilepsy (in 19 out of 46 patients; 41%), but not in those with PNES only (in 4 out of 86 patients; 5%) (p = 0.00001). While the evidence is convergent on the relatively high prevalence of structural brain abnormalities in patients with PNES, the data so far is suboptimal. In order to investigate the significance of structural brain abnormalities in the development of PNES, future well-designed multicenter studies, which include a large number of patients with a unified methodology of imaging, are desirable.

Purpose The aim of the current study was to depict a comprehensive geographical picture of the existing literature on psychogenic nonepileptic seizures (PNES) and to highlight the needs for future works. Methods We searched the electronic database PubMed on June 8, 2019 for articles that included any of the related key words to analyze all the relevant literature. We applied the advance search; field was adjusted to the title and dates were adjusted to 01/01/2000 until 06/08/2019. We selected the relevant articles. Location of the study was determined according to the affiliation(s) of the authors. Results 1017 papers were included. Interest in research and publication on PNES has risen over the past two decades. Six hundred and nine full length research original papers and 199 review articles were published on PubMed from 2000 until 2019. Continent-wise, most articles were from North America and Europe (41.1% of the whole publications from Europe and 40.8% from North America; 833 papers totally), followed by Asia (92 papers), Oceania (36 papers) and South America (31 publications), while only 0.9% of the papers (9 papers) were from Africa. Conclusion A global campaign is necessary to inform and educate the world on the issue of PNES and its significance. While PNES merit further epidemiological investigations, there is a significant disparity with regard to the location of the studies. There is a huge need to invest more on studies on various aspects of PNES in many places in the world, including African nations, India, and China.

Purpose The aim of the current study was to systematically review the literature to compare the efficacy of levetiracetam (LEV) with that of carbamazepine (CBZ) to control seizures and reduce the burden of interictal epileptiform discharges in children with rolandic epilepsy (RE) and also to compare their tolerability. Methods We searched the electronic database PubMed on January 9, 2019 for original articles that included the following English-language search terms in the title: “Rolandic epilepsy” OR “benign childhood epilepsy with centrotemporal spikes” since 2000. We concentrated our review on three main areas: 1. Neuropsychological impairments in children with RE; 2. Influence of epileptic activity on cognitive performance in RE; 3. Effects of antiepileptic drug (AED) therapies in RE. Results The primary search yielded 308 papers. We reviewed the results and removed duplicate articles and all nonoriginal, non-English papers. Finally, after carefully reviewing the full texts, we included 44 original articles to achieve the aims of this review. Conclusion Physicians taking care of children with RE should be aware of the risks for cognitive dysfunctions in these patients and screen their patients for any subtle dysfunction that may affect their academic performance and achievement. If and when the physician decides to prescribe an AED for their patients with RE, LEV is probably a better option compared with CBZ to prescribe for these children.

Objective: To develop and validate a pragmatic algorithm that classifies seizure types, to facilitate therapeutic decision-making. Methods: Using a modified Delphi method, five experts developed a pragmatic classification of nine types of epileptic seizures or combinations of seizures that influence choice of medication, and constructed a simple algorithm, freely available on the internet. The algorithm consists of seven questions applicable to patients with seizure onset at the age of 10 years or older. Questions to screen for nonepileptic attacks were added. Junior physicians, nurses, and physician assistants applied the algorithm to consecutive patients in a multicenter prospective validation study (ClinicalTrials.gov identifier: NCT03796520). The reference standard was the seizure classification by expert epileptologists, based on all available data, including electroencephalogram (EEG), video-EEG monitoring, and neuroimaging. In addition, physicians working in underserved areas assessed the feasibility of using the web-based algorithm in their clinical setting. Results: A total of 262 patients were assessed, of whom 157 had focal, 51 had generalized, and 10 had unknown onset epileptic seizures, and 44 had nonepileptic paroxysmal events. Agreement between the algorithm and the expert classification was 83.2% (95% confidence interval = 78.6%–87.8%), with an agreement coefficient (AC1) of.82 (95% confidence interval =.77–.87), indicating almost perfect agreement. Thirty-two health care professionals from 14 countries evaluated the feasibility of the web-based algorithm in their clinical setting, and found it applicable and useful for their practice (median = 6.5 on 7-point Likert scale). Significance: The web-based algorithm provides an accurate classification of seizure types, which can be used for selecting antiseizure medications in adolescents and adults.

Background To identify the prevalence and also the full spectrum of symptoms/complaints of children and adolescents who are suffering from long COVID. Furthermore, we investigated the risk factors of long COVID in children and adolescents. Methods All consecutive children and adolescents who were referred to the hospitals anywhere in Fars province, Iran, from 19 February 2020 until 20 November 2020 were included. All patients had a confirmed diagnosis of COVID-19. In a phone call to patients/parents, at least 3 months after their discharge from the hospital, we obtained their current status and information if their parents agreed to participate. Results In total, 58 children and adolescents fulfilled the inclusion criteria. Twenty-six (44·8%) children/adolescents reported symptoms/complaints of long COVID. These symptoms included fatigue in 12 (21%), shortness of breath in 7 (12%), exercise intolerance in 7 (12%), weakness in 6 (10%), and walking intolerance in 5 (9%) individuals. Older age, muscle pain on admission, and intensive care unit admission were significantly associated with long COVID. Conclusions Long COVID is a frequent condition in children and adolescents. The scientific community should investigate and explore the pathophysiology of long COVID to ensure that these patients receive appropriate treatments for their condition. Supplementary Information The online version contains supplementary material available at 10.1007/s12519-021-00457-6.

Objectives To investigate the seizure outcome with medical treatment in patients with temporal lobe epilepsy (TLE) and its associated factors. We also investigated the social outcome of the patients. Methods This was a retrospective study of a prospectively built electronic database of patients with epilepsy. All patients with a diagnosis of TLE were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2019. In a phone call to the patients, at least 24 months after their diagnosis at our center, we investigated their current seizure control and social status. Results Two hundred and twenty-two patients were studied; 101 patients (45.5%) were seizure free. A lower number of the prescribed drugs was the only factor with a significant association with the seizure-free outcome (Odds Ratio: 1.460; p = 0.001). At the time of the phone call, 76 patients (37.6%) reported having a college education, 103 patients (51%) were employed, 146 patients (72.3%) were married, and 81 patients (40%) reported driving a motor vehicle. The employment status, college education, and driving a motor vehicle were significantly associated with a seizure-free outcome status. The social achievements of the patients, who were partially responsive to medical therapy, were significantly worse than those who were seizure free. Conclusion Many patients with TLE may suffer from drug-resistant seizures. Ongoing seizures in these patients may affect their social lives substantially. Seizure reduction (not freedom) is not good enough to help the patients with TLE enjoy a healthy life with satisfactory social achievements.

The relationship between functional seizures (FS) and sexual trauma has received attention in many previous studies. However, the mechanisms underlying this relationship have not been elucidated yet. The purpose of this narrative review is to explore and speculate on the underpinning neurobiological mechanisms for the association and link between sexual trauma and functional seizures. While existence of a causal relationship between a history of sexual trauma and functional seizures is plausible, it should be viewed and treated as a hypothesis. In explaining this hypothesis, we can speculate that interactions between genetic factors and a history of sexual trauma may contribute to the risk of experiencing functional seizures. Childhood sexual trauma may lead to structural and functional connectivity changes in the brain and dysregulation of the biological stress systems, particularly in women. These neurobiological changes speculatively may predispose patients to functional seizures later in life. Importantly, a history of sexual trauma has many other implications beyond the predisposition towards FS.

Objective We investigated the marital status (married vs. none) among patients with seizures [i.e., epilepsy or functional seizures (FS)]. Methods This was a retrospective study of an electronic database of patients with seizures. All young adult patients, 18 to 45 years of age, with a diagnosis of either epilepsy or FS were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020. The two groups were matched for their age at diagnosis. Age at onset, sex, the marital status, and the final diagnosis were registered routinely. Results During the study period, 194 patients with FS and 455 patients with epilepsy fulfilled the inclusion criteria. The rates of the married status were not significantly different between the two groups; 101 patients with FS (52%) and 204 PWE (45%) were married (p = 0.103). In the general population in Iran, 42,399,792 out of 66,421,989 (64%) of all people older than 16 years of age were married. This rate is significantly higher than the rate of the married status among patients with FS (p = 0.0006) and also those with epilepsy (p = 0.00001). Conclusion While the rates of the married status were not significantly different between PWE and those with FS, these rates were significantly lower than that in the general population in Iran. There are intriguing cross-cultural similarities and differences between our observations and those from other nations. These should be investigated in large multicenter international studies in the future.

Periodic electroencephalographic (EEG) patterns are frequently recorded during ICU EEG monitoring in patients with altered mental status; these EEG features represent electrical discharges, ictal in appearance, occuring at regular intervals. They are known as lateralized periodic discharges (LPDs), bilateral independent periodic discharges (BIPDS), generalized periodic discharges (GPDs), continuous 2/s GPDs with triphasic morphology or triphasic waves (TWs) and Stimulus Induced Evolving Lateralized Rhytmic delta activity or Si-Evolving LRDA (previously SIRPIDS); other periodic, rhythmic patterns are Occasional frontally predominant brief 2/s GRDA (FIRDA previously), Lateralized rhythmic delta activity (LRDA) and Brief potentially ictal rhythmic discharges or B (I)RDs. The role of most (not all) of these EEG patterns is controversial; there is no consensus on which patterns are associated with ongoing seizure injury, which patterns need to be treated, and how aggressively they should be treated. Many authors consider these patterns as an unstable state on an ictal-interictal EEG continuum; the aim of the present chapter is to gain knowledge of these EEG features, show their association with known neurologic pathologies/syndromes and finally how to manage them.

Objectives We applied the Two-Step cluster analysis on a large cohort of patients with Lennox-Gastaut syndrome (LGS). We hypothesized that there are distinct clusters of patients with LGS based on their clinical characteristics. We also studied whether the seizure outcome differs between these patient clusters. Methods This was a longitudinal study of a prospectively developed database. All patients with a diagnosis of LGS were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020. The Two-Step cluster analysis (Schwarz's Bayesian Criterion: BIC) was applied to the whole dataset considering the demographic data, seizure types, and EEG data. In the next step, the seizure outcome was compared between the clusters of patients. Results Two hundred and fifty-eight patients were studied. The Two-Step cluster analysis showed that there were three clusters of homogeneous subgroups of patients with LGS, with a fair silhouette measure of cohesion and separation. The seizure outcomes were significantly different between the clusters. In cluster 1, three out of 35 patients (8.6%) were seizure-free; in cluster 2, 13 out of 34 patients (38.2%) were seizure-free; and in cluster 3, nine out of 49 patients (18.4%) were seizure-free (p = 0.009; df: 2). Conclusion The Two-Step cluster analysis could identify three distinct clusters of patients with LGS; these data are helpful in providing appropriate prognosis and counselling for patients and their care-givers. Future studies should also investigate the effects of etiology in cluster analysis of patients with LGS.

Background We systematically reviewed the existing literature on the cosmetic adverse effects of antiseizure medications (ASMs) in order to depict a clear picture of these unwanted side effects of ASMs with a particular attention to hair loss, hirsutism, acne, and gingival hyperplasia. Methods This systematic review was prepared according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Scopus, MEDLINE, and Google Scholar from the inception to 25 March, 2021 were systematically searched. These key words (title/abstract) were used: “hair loss” OR “hirsutism” OR “acne” OR “gingival hyperplasia” AND “seizure” OR “epilepsy” OR “anriseizure” OR “antiepileptic”. The exclusion criteria included: non-original studies, articles not in English, and animal studies. Results The primary search yielded 3938 studies; 127 studies were related to the topic and were included in the current systematic review. The most robust evidence on cosmetic adverse effects of ASMs were related to phenytoin (causing gingival hyperplasia, hirsutism, and acne) and valproate (causing hair loss and hirsutism); however, many other ASMs were also implicated in causing these cosmetic adverse effects. Conclusion Antiseizure medications may be associated with various cosmetic adverse effects. Phenytoin and valproate are the most notorious ASMs in this regard; but, other ASMs have also been implicated in causing hair loss, hirsutism, acne, and gingival hyperplasia. Physicians should pay more attention to these significant adverse effects that may affect a patient's facial attractiveness, quality of life, and emotional state.

Introduction: Despite more than one year passed since the first cases of SARS-CoV-2 were reported, there is still no consensus on the definition and clinical management of post-acute-COVID-19. The condition has heterogeneously been named as Chronic COVID syndrome, Post COVID-19 Syndrome, post-acute sequela of SARS-CoV-2 (PASC), and the more familiar long COVID. Method: In order to capture all relevant published studies, we undertook a multi-step search with no language restriction. The following four-step search strategy was utilized: First, a preliminary (limited) search was conducted on January 20, 2021, in Google Scholar and PubMed to identify the appropriate keywords. Then, on January 30, 2021, we adopted a search strategy of electronic databases from Cochrane Library, PsycINFO, PubMed, Embase, Scopus, and Web of sciences, using those keywords. Then, after duplicate removal, we screened all titles, abstracts, and full texts. This resulted in 66 eligible studies. Subsequently, after a forward and backward search of their references and citations an additional 54 publications were found, resulting in a total of 120 publications that formed the basis of the present analysis. The titles, abstracts, and full-texts of non-English articles were translated using Google Translate for further evaluation. We conducted our scoping review based on the PRISMA-ScR Checklist.Results: We found only one randomized clinical trial in our search. Of the 67 original studies, 22 were cohort and 28 were cross-sectional studies totaling 74.6% of the original studies. Of the total of 120 publications, 59 (49.1%) focused on signs and symptoms, 28 (23.3%) were focused on management, and 13 (10.8%) focused on pathophysiology. Ten (9%) publications focused on imaging studies. Ninety-one percent of the original investigations came from high and upper-middle-income countries, highlighting the scarcity of reports originating from low-income and lower-middle-income countries.Conclusion: The predominant symptoms among those with the so-called “Long COVID” were: fatigue, breathlessness, arthralgia, sleep difficulties, and chest pain. Recent reports also point to the risk of long-term sequela with cutaneous, respiratory, cardiovascular, musculoskeletal, mental health, neurologic, and renal involvement in those who survive the acute phase of the illness. The ambiguity and controversies in its definition have impaired proper recognition and management of those requiring additional support following the resolution of the acute phase of this infection. This has resulted in long-standing distress for the patients and their families. Our findings highlight the need for a multidisciplinary approach, support, and rehabilitation for these patients in terms of long-term mental and physical health.

Background Postictal headache (PIH) is a common complaint among patients with epilepsy. The prevalence of PIH is 43%. In the current endeavor, we systematically reviewed the existing treatment options for PIH in order to depict the state of the field and also to propose a research agenda to advance this topic. Methods MEDLINE, Scopus, and Embase from the inception to 4 February, 2021 were systematically searched for related published articles. In all electronic databases, the following search strategy was implemented and these key words (in all fields) were used: “post-ictal” AND “Headache” AND “Treatment”. Results The primary search yielded 626 studies; only five studies were related to the topic and were included in the current systematic review. None of these studies provided a good class of evidence. These studies suggested that flunarizine and sumatriptan may help patients with PIH. Conclusion While PIH is a common and disabling condition, its treatment is overlooked by the epilepsy society. Flunarizine and sumatriptan can be good candidates to be used in future clinical trials of the treatment of PIH. To obtain the desired evidence on the efficacy of either flunarizine or sumatriptan in treating PIH in patients with epilepsy, we need well-designed, randomized controlled trials.

Highlights • 5,872 patients were admitted to hospitals with COVID-19 during the study period. • 45 came to the emergency room with seizures. • This makes seizure as the presenting manifestation of COVID-19 in 0.8% of all patients with a severe illness. • Seizures happened in both sexes and all age groups and most people had de novo seizures., Objective The aim of the current study was to investigate whether seizure is among the presenting manifestations of COVID-19. Methods All patients referred to emergency rooms anywhere in Iran between 12 and 25 April 2020 and who were sufficiently ill to require hospital admission with COVID-19, confirmed by a positive COVID-19 test, were studied. Data on the presenting manifestations were collected. Results Of 5872 people, who were admitted to hospitals in Iran with COVID-19 during the study period, 45 came to the emergency room with seizures. This makes seizure as the presenting manifestation of COVID-19 in 0.8 % of all patients with a severe illness. 93 % of the patients were 15 years of age and older. Four of the individuals presenting with seizures (9%) had a past history of epilepsy. Fifteen of these individuals (33 %) had other chronic medical conditions (e.g., cancer, diabetes mellitus, heart disease, etc.). Conclusion This case series provides evidence that seizures are among the presenting manifestations of COVID-19 in 0.8 % of the patients who are admitted to hospital due to a severe illness.

Objectives The aim of the current study was to compare the frequency of significant head injuries in three groups of people with seizures [idiopathic generalized epilepsies (IGE) vs. temporal lobe epilepsy (TLE) vs. functional seizures (FS)]. Methods This was a retrospective study. All patients with a diagnosis of IGE, TLE, or FS were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020. Results One thousand and four hundred ninety-two patients were studied (559 patients with IGE, 646 people with TLE, and 287 persons with FS). Overall, 77 (5.2%) individuals of the studied people reported experiencing severe head injuries before the onset of their seizures [9 patients (1.6%) with IGE, 56 people (8.7%) with TLE, and 12 persons (4.2%) with FS; p = 0.0001]. Compared to people with IGE, the odds ratio of having a premorbid history of severe head injury in the FS group was 2.67 [95% Confidence Interval (CI): 1.11–6.40; p = 0.0280]. Compared to people with TLE, the odds ratio of having a premorbid history of severe head injury in the FS group was 0.46 (95% CI: 0.24–0.87; p = 0.0170). Conclusion Severe head injury is significantly associated with FS. However, since head injury is also a significant risk factor for focal epilepsies, it may be necessary to ascertain the diagnosis of post-traumatic seizures by obtaing a detailed clinical history and also by performing video-EEG monitoring in order to adopt an appropriate treatment strategy in these patients.

Purpose The aim of the current study was to determine whether COVID-19 is associated with a different presenting clinical picture or a more severe course of illness in people with Down syndrome (DS). Methods All consecutive patients who were admitted at healthcare facilities anywhere in Fars province (located in the south of Iran with a population of 4,851,000 people) from 19 February 2020 to 20 November 2020 were included. For every patient with DS, three age- and sex-matched patients with COVID-19 and without any underlying medical conditions were selected as controls. Results During the study period, 37,968 patients were hospitalized with a diagnosis of COVID-19. Eighteen patients had DS. Patients with DS were significantly more likely to be intubated [7 patients (39%)] compared with those without DS [3 patients (6%)]; p = 0.002. Patients with DS significantly more often died of COVID-19 compared with the controls [8 (44.4%) vs. 1 (1.9%); odds ratio: 24.37; 95% confidence interval 2.39–247.94; p = 0.007]. Conclusion Patients with DS are among the high-risk populations with respect to severe COVID-19 and should receive the vaccine as soon as possible. Furthermore, they should receive more intensive care if they get hospitalized with the illness.

To compare auras between three groups of people with seizures [i.e., Idiopathic generalized epilepsies (IGE) vs. Temporal lobe epilepsy (TLE) vs. Functional seizures (FS)].All patients, 10 years of age or older, with a diagnosis of IGE, TLE, or FS were prospectively registered in an electronic database and retrospectively studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020.One thousand and three hundred ninety-one patients were studied (480 with IGE, 617 with TLE, and 294 with FS). Among patients with TLE, 63.5% of individuals reported auras; this figure was 68% in the FS and 12.7% in the IGE groups (p0.00001). Odds ratio of having auras in the TLE group compared with the IGE group was 11.96 (95% CI: 8.73-16.39; p = 0.0001). Odds ratio of having auras in the TLE group compared with the FS group was 0.81 (95% CI: 0.61-1.10; p = 0.1840). Odds ratio of having auras in the FS group compared with the IGE group was 14.61 (95% CI: 10.15-21.02; p = 0.0001). The following auras were more frequent among patients with TLE: emotional, cognitive, epigastric, and olfactory/gustatory. The following auras were more frequent among patients with FS: headache and dizziness/vertigo.Auras are not specific to focal epilepsies. Future studies should investigate auras in large cohorts of patients with focal or generalized epilepsies and also those with FS to determine the exact clinical value of each aura.