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      How Helpful Is aEEG? Context and User Experience Matter

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          Abstract

          Objective  The aim of the study is to model amplitude-integrated electroencephalography (aEEG) utility to diagnose seizures in common clinical scenarios.

          Study Design  Using reported neonatal seizure prevalence and aEEG sensitivities and specificities, likelihood ratios (LRs) and post-test probabilities were calculated to quantify aEEG utility to diagnose seizures in three typical clinical scenarios.

          Results  Prevalence data supported pretest probabilities for neonatal seizures of 0.4 in neonatal hypoxic ischemic encephalopathy (HIE), 0.27 in bacterial meningitis, and 0.05 in extreme prematurity. Reported sensitivity of 85% and specificity of 90% for seizures with expert aEEG interpretation yielded a positive likelihood ratio (LR+) of 8.7 and a negative likelihood ratio (LR−) of 0.17. Reported sensitivity of 65% and specificity of 70% with intermediate interpretation yielded LR+ 2.17 and LR− 0.5. Reported sensitivity of 40% and sensitivity of 50% with inexperienced interpretation gave LR+ 0.8 and LR− 1.2. These translate the ability to move pretest to post-test probability highly dependent on user expertise. For HIE, a pretest probability of seizure of 0.4 moves to a post-test probability of 0.85 when aEEG is positive for seizures by expert interpretation, and down to 0.1 when aEEG is negative. In contrast, no useful information was gained between pretest and post-test probability by aEEG interpreted as negative or positive for seizure at the inexperienced user level. Similarly, in the models of meningitis or extreme prematurity, incremental information gained from aEEG ranged widely based on interpreter experience.

          Conclusion  aEEG is most useful to screen for neonatal seizures when used in conditions with high seizure prevalence, and when interpretation has a sensitivity and specificity as reported for expert users. In contrast, aEEG can become negligible in providing meaningful clinical information when applied in conditions having lower seizure prevalence or when interpretation has low accuracy. Appropriate patient selection and high quality interpretation are essential for aEEG utility in neonatal seizure detection.

          Key Points

          • aEEG utility for neonatal seizure screening relies on patient selection and quality interpretation.

          • Utility of aEEG is highest with high seizure prevalence and expert interpretation.

          • Utility of aEEG can be negligible with lower seizure prevalence or low accuracy interpretation.

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          Most cited references15

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          Contemporary Profile of Seizures in Neonates: A Prospective Cohort Study

          To determine the contemporary etiology, burden, and short-term outcomes of seizures in neonates monitored with continuous video-electroencephalogram (cEEG).
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            Neonatal Bacterial Meningitis: 444 Cases in 7 Years.

            Neonatal bacterial meningitis remains a severe infectious disease with mortality rates varying between 10% and 15%. The clinical and bacteriologic features of neonatal meningitis collected from January 2001 to December 2007 in a French national survey are presented here. Cases of neonatal meningitis were prospectively collected by a network of 252 pediatric wards covering 61% of French pediatric wards, associated with 168 microbiology laboratories. Neonatal meningitis was classified as early-onset (d0-d4) and late-onset (d5-d28). Statistical analyses were performed according to gestational age and weight at birth. A total of 444 cases of neonatal bacterial meningitis were reported by 114 pediatric wards. Five cases were excluded from analysis. Group B streptococci (GBS) and Escherichia coli accounted respectively for 59% and 28% of the cases, followed by Gram-negative bacilli other than E. coli (4%), other streptococci (4%), Neisseria meningitidis (3%), and Listeria monocytogenes (1.5%). GBS was the most common pathogen both in early-onset (77% vs. 18% for E. coli) and in late-onset meningitis (50% vs. 33% for E. coli). Among preterm infants, E. coli was more commonly isolated (45% vs. 32% for GBS), especially in very preterm infants (54%). GBS was more often involved in seizures than E. coli (41% vs. 25%). The overall mortality rate was 13% but reached 25% in preterm or small for gestational age infants, regardless of the etiology. GBS was the dominant cause of neonatal bacterial meningitis, with 77% of early-onset and 50% of late-onset cases. E. coli was the most common bacteria in preterm infants.
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              • Article: not found

              Electrographic Seizures during the Early Postnatal Period in Preterm Infants.

              To investigate the frequency and characteristics of electrographic seizures in preterm infants in the early postnatal period.
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                Author and article information

                Journal
                Am J Perinatol
                Am J Perinatol
                10.1055/s-00000009
                American Journal of Perinatology
                Thieme Medical Publishers, Inc. (333 Seventh Avenue, 18th Floor, New York, NY 10001, USA )
                0735-1631
                1098-8785
                15 December 2020
                July 2022
                1 December 2020
                : 39
                : 10
                : 1132-1137
                Affiliations
                [1 ]Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
                [2 ]Division of Child Neurology and Division of Pediatrics—Neonatal and Developmental Medicine, Stanford University, Palo Alto, California
                Author notes
                Address for correspondence Amanda G. Sandoval Karamian, MD 3501 Civic Center Boulevard, Office 1200.12, Philadelphia, MA 19104 sandovalka@ 123456email.chop.edu
                Author information
                http://orcid.org/0000-0002-0813-1334
                Article
                200474
                10.1055/s-0040-1721711
                9325066
                33321530
                96140486-43f0-41ff-a077-19995f3d9e95
                The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ )

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

                History
                : 04 June 2020
                : 02 November 2020
                Categories
                Original Article

                amplitude-integrated eeg,neonatal neurology,neonatal seizures,brain monitoring

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