One third of the overall epilepsy population are estimated to be a drug refractory epilepsy (DRE), defined as the patients who failed to control seizure reduction, even tried two or more appropriate antiepileptic drugs (AEDs) trials. Those people need additional AEDs trials or other treatment options (resective surgery, neuromoulation, etc.). Here, we, clinical guideline committee of the Korean Neurological Association (KNA) introduce the recommendations of AEDs treatments including not only old and new AEDs currently available in Korea but also AEDs planned to be launched in the new future for DRE patients with literature review to help efficient decision of the clinician. The authors reviewed literatures and assessed efficacy and tolerability on 12 currently available and four newly introduced/or planned AEDs applied to DRE patients, published from November 2015 to July 2021. Brivaracetam, eslicarbazepine, canabidiol and cenobamate are the four AEDs that are newly introduced or planned to be launched soon. The reviewed articles are publications after November 2015, 2018 American Association of Neurology guideline, new AEDs which were introduced or planned to be launched as of 2021. All AEDs are classified based on the therapeutic rating scheme, generating recommendations. Overall 173 papers have been reviewed and analyzed for recommendation rationales. KNA introduce additional add-on treatment or conversional monotherapy guidelines on the drug refractory focal and generalized epilepsy. We hope these guidelines or recommendations to help clinical decision for the treatment of drug refractory epilepsy patients

BACKGROUND: It is important to define a source of infection when outbreak of Legionella infections has occurred. The performance of a molecular strain typing method was evaluated for environmental and clinical isolates of Legionella pneumophila. METHODS: Thirteen environmental strains, eleven clinical isolates and one type strain (ATCC 33152) of Legionella pneumophila were used for the analysis of pulsed field gel electrophoresis. RESULTS: All 25 strains were discriminated into 21 types. Two strains isolated from different locations in a same building showed different types. Each two, four, and two strains were shown as the same PFGE patterns. CONCLUSIONS: Even though PFGE typing of Legionella pneumophila is excellent for strain differentiation, the same pattern does not necessarily indicate the same source of isolates.
Busan* ; Electrophoresis, Gel, Pulsed-Field ; Korea* ; Legionella pneumophila ; Legionella* ; Water*

BACKGROUND: The purpose of this study was to localize the cortical regions reflected by overlying scalp electrodes. METHODS: We enrolled 10 patients with epilepsy (5 males, mean age 29.7 years old). Thin slice coronal T1 weighted MR images were obtained and then scalp EEG electrodes were placed based on an international 10-20 system. Cortical locations of scalp electrodes were determined using a real-time frameless stereotactic image guidance system, Brainsight(R). RESULTS: The locations of 19 scalp electrodes were marked on the 3D rendered cortical surface of one representative patient's MRI; Fp1 (Fp2) on the anterior pole of the middle frontal gyrus, Fz on the mid-point of the interhemispheric fissure in the frontal lobe, F3 (F4) on the mid-portion of the middle frontal gyrus, F7 (F8) on the pars triangularis of the inferior frontal gyrus, Cz on the interhemispheric fissure where a lateral precentral gyrus starts, C3 (C4) scattered around postcentral gyrus, T3 (T4) on the middle temporal gyrus, P3 (P4) on the angular gyrus, Pz on the mid-point of the interhemispheric fissure in the parietal lobe, T5 (T6) on the posterior part of the inferior temporal gyrus, and O1 (O2) on the occipital pole. CONCLUSIONS: The locations of scalp electrodes were well correlated with conventional concepts of their cortical locations. The individual differences of the scalp electrode locations may be due to the different sizes and morphologies of the brains in each of the patients. Real time cortical localization of scalp electrodes using the Frameless Stereotactic Image Guidance System may provide useful information for more accurate localization of focal cerebral activity in partial epilepsy patients.
Brain* ; Electrodes* ; Electroencephalography ; Epilepsies, Partial ; Epilepsy ; Frontal Lobe ; Humans ; Individuality ; Magnetic Resonance Imaging ; Male ; Neuronavigation ; Parietal Lobe ; Scalp*

In determination of brain death, brain CT angiography (CTA) can be used as a new ancillary test to assist EEG which is the current gold standard. We report a patient with barbiturate coma therapy whose CTA showed weak filling of the internal carotid artery and its branches when his EEG demonstrated regional beta activities in the corresponding area, which finally disappeared. Combined use of CTA and serial EEGs would be helpful as brain death testing in a patient with barbiturate coma therapy.
Angiography* ; Brain Death* ; Brain* ; Carotid Artery, Internal ; Coma* ; Electroencephalography ; Humans ; Pentobarbital ; Subarachnoid Hemorrhage*

PURPOSE: Status epilepticus (SE) is a pathologic state where pharmacokinetic alterations can be more pronounced and more rapid than during the other epileptic states. The consequences of such changes can exert negative influences on the timely adequate treatments for stopping uncontrolled seizures during SE. Topiramte (TPM) is one of new antiepileptic drugs with high efficacy in epilepsy, which can also be effectively used in SE. The aim of this study was to evaluate the pharmacokinetic changes during the SE by an analysis of the therapeutic drug monitoring (TDM) of TPM in patients with SE.METHODS: We retrospectively analyzed 49 serum measurements of TPM from 22 subjects with SE. The serum concentrations of TPM were measured by HPLC-tandem mass spectrometry. TDM data were categorized into malignant status epilepticus (MSE), refractory status epilepticus (RSE), and non-status epilepticus (NSE) groups. We compared concentration-to-dose ratio (CDR) among those groups.RESULTS: Among 49 cases, 11 were in MSE, 19 in RSE, and 19 in NSE. The daily dose of TPM was higher in MSE (median, interquartile range: 600, 600-800 mg) than in RSE (300, 250-600 mg) and NSE (200, 150-400 mg). The daily dose adjusted for body weight was also higher in MSE (12.2, 10.4-13.9 mg/kg) than in RSE (4.5, 3.8-12.2 mg/kg) and NSE (4.1, 2.3-7.1 mg/kg) (p<0.01). Serum concentrations of TPM were less in MSE (5.8, 4.2-7.3 mg/L) and RSE (4.9, 2.9-6.0 mg/L) than in NSE (5.5, 3.3-9.0 mg/L), which were not significantly different among the groups (p>0.1). However, the concentration-to-dose ratio (CDR) was significantly lower in MSE (0.41, 0.35-0.59 kg/L) and RSE (0.85, 0.39-1.23 kg/L) than in NSE (1.72, 0.96-2.24 kg/L) (post hoc analysis, p<0.005, 0.05).CONCLUSIONS: The serum concentrations of TPM can be influenced by SE, particularly in MSE. The higher range of dose of TPM could be needed for an adequate treatment of SE.
Anticonvulsants ; Body Weight ; Drug Monitoring ; Epilepsy ; Fructose ; Humans ; Mass Spectrometry ; Retrospective Studies ; Seizures ; Status Epilepticus

OBJECTIVE: Whether long-acting injectable antipsychotics (LAI) are superior to oral antipsychotics remains a controversial question, and results vary depending on the study design. Our study was performed to compare outcomes of oral anti-psychotics and paliperidone palmitate (PP) in clinical practice by investigating the numbers of admissions and bed days. METHODS: We performed a retrospective observational mirror-image study at a single medical center, reviewing medical charts to obtain the clinical data. Forty-six patients with a diagnosis of schizophrenia or schizoaffective disorder who had received at least two doses of PP were included in the analysis. The Wilcoxon signed-rank test was used to compare the numbers of bed days and admissions 1 year before starting PP with those numbers at 1 year after. RESULTS: The mean number of admissions fell from 0.83 to 0.17 per patient (p < 0.0002), and the median fell from 1 to 0. The mean number of bed days decreased significantly, from 24.85 to 8.74 days (p < 0.006). The outcomes remained similar in sensitivity analyses set up with different mirror points. CONCLUSION: Our results indicate that initiating PP reduced the mean numbers of hospital admissions and bed days compared with prior oral medication. LAIs may thus be cost effective in practice; its use bringing about cost reductions greater than its purchase cost.
Antipsychotic Agents ; Diagnosis ; Hospitalization ; Humans ; Paliperidone Palmitate ; Psychotic Disorders ; Retrospective Studies ; Schizophrenia

Objectives: The aim of this study is to evaluate relationship of health-related quality of life (HRQoL) with chronotype along with quality and quantity of sleep in Korean middle adults. Methods: Data was derived from the nationwide, cross-sectional study on sleep surveyed 2,501 representative adult Koreans. We collected data from 1,435 participants aged ≥35 years and <65 years to represent Korean middle adults. The Chronotype Questionnaire was used to assess phase and distinctiveness of the circadian rhythm. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality. Quantity of sleep was investigated by questions regarding sleep habits during workdays and free days. EuroQol-5D 3-level version was used to measure HRQoL. Results: On univariable analyses, eveningness is associated with younger age (47.7±8.2 vs. 51.3±8.1 years, p<0.001), and higher PSQI total score (4.3±2.7 vs. 3.6±2.2, p<0.001) compared with morningness. Strong distinctiveness also associated with higher PSQI total score (4.2±2.3 vs. 3.6±2.5, p< 0.001) compared with weak distinctiveness. Age was not different between the two groups of distinctiveness. On multivariable analyses, strong distinctiveness is an independent factor predicting impairment of pain/discomfort [odd ratio (OR) 1.589, 95% confidence interval (CI) 1.182–2.130] and depression/anxiety (OR 1.412, 95% CI 1.003–1.987). Poor sleep quality was the most powerful independent factor predicting impairments in all five domains of the HRQoL. Conclusions Sleep quality is an important factor independently related to the HRQoL. Among chronotype variables, only distinctiveness has an independent relation with the HRQoL.

Antiepileptic drugs (AEDs) are the primary treatment strategy for epilepsy. As the use of AEDs has become more widespread and diverse over the past century, it has become necessary to refine the associated prescription strategies. This prompted the Drug Committee of the Korean Epilepsy Society to perform a systemic review of both international and domestic guidelines as well as literature related to medical treatment of epilepsy, and prepared a series of reviews to provide practical guidelines for clinicians to follow. This article is the first in a series on AED treatments for epilepsy in South Korea.

The incidence and prevalence of epilepsy are highest in elderly people, and the etiologies of epilepsy in the elderly differ from those in other age groups. Moreover, diagnosing and treating epilepsy in elderly people may be challenging due to differences in clinical characteristics and physiological changes associated with aging. This review focuses on the pharmacological treatment of epilepsy in elderly patients.

Autoimmune epilepsy is a newly emerging area of epilepsy. The concept of “autoimmune” as an etiology has recently been revisited thanks to advances in autoimmune encephalitis and precision medicine with immunotherapies. Autoimmune epilepsy presents with specific clinical manifestations, and various diagnostic approaches including cerebrospinal fluid analysis, neuroimaging, and autoantibody tests are essential for its differential diagnosis. The diagnosis is often indeterminate despite performing a thorough evaluation, and therefore empirical immunotherapy may be applied according to the judgment of the clinician. Autoimmune epilepsy often manifests as new-onset refractory status epilepticus (NORSE). A patient classified as NORSE should receive empirical immunotherapy as soon as possible. On the other hand, a morecautious, stepwise approach is recommended for autoimmune epilepsy that presents with episodic events. The type of autoimmune epilepsy is also an important factor to consider when choosing from among various immunotherapy options. Clinicians should additionally take the characteristics of antiepileptic drugs into account when using them as an adjuvant therapy. This expert opinion discusses the diagnostic and treatment approaches for autoimmune epilepsy from a practical point of view.