Early specialized care after a first unprovoked epileptic seizure.

A first seizure is a life-changing event with physical and psychological consequences. We aimed to assess the role of early comprehensive patient care after a first unprovoked seizure to improve diagnostic accuracy and follow-up adherence. From April 2011 to March 2012, patients presenting a first unprovoked epileptic seizure received standard patient care (SPC), i.e., a consultation in the ED, an EEG and a CT scan. The patients were notified of the follow-ups. We compared this protocol to subsequently acquired "early comprehensive patient care" (ECPC), which included a consultation by an epileptologist in the emergency department (ED), a routine or long-term monitoring electroencephalogram (LTM-EEG), magnetic resonance imaging and three follow-up consultations (3 weeks, 3 months, 12 months). 183 patients were included (113 ECPC, 70 SPC). LTM-EEG and MRI were performed in 51 and 85 %, respectively, of the patients in the ECPC group vs in 7 and 52 % of the patients in the SPC group (p < 0.001). A final diagnosis was obtained in 64 vs 43 % of the patients in the ECPC vs SPC group (p < 0.01). Patient attendance at 3-month was 84 % in the ECPC group vs 44 % in the SPC group (p < 0.001). At 12-month follow-up, the delay until the first recurrence was longer in the ECPC group (p = 0.008). An early epileptologist-driven protocol is associated with clinical benefit in terms of diagnostic accuracy, follow-up adherence and recurrence. This study highlights the need for epilepsy experts in the early assessment of a first epileptic seizure, starting already in the ED.

Integrated development and maturation of the hearing system. A critical review article.

The understanding of development and maturation of the auditory system is essential for many reasons, including the practical aspects of auditory behaviour, testing, and teaching a hearing-impaired child to communicate effectively. The study of maturation of the auditory system is gaining increasing importance also because it should help us to interpret correctly certain aspects of auditory behaviour in infants. When studying the auditory system we should not be concerned solely with development of function in isolation; the emphasis is on integrated development. Understanding a process of integrated development enables us to understand the peculiarities of auditory behaviour in infants. Sound became the raw material of human language for good reasons. It is the only medium which made it possible to transmit efficiently complex information encoded in human language. Phylogenetically, hearing in vertebrates is a late development, and because of this, in certain unfavourable circumstances the hearing system is more vulnerable than other phylogenetically older systems. Within the auditory system, high-frequency hearing is also phylogenetically a late development, and therefore more vulnerable to certain unfavourable metabolic influences. In all species there is a 'best frequency' range, usually the one which is most vital for communication. In humans the best frequency range is the one which is most important for transmitting speech sounds. This is already noticeable in newborn and very young infants, that is, we can obtain the best reactions in the frequencies which are important for speech. Higher sensitivity for perception of patterns is already developed in newborn and young infants (and acquires a special significance). Direction detection and localisation of sound source develops gradually. It is fully developed only when the auditory pathway matures and when the function is well integrated with the maturing motor system. The ears of the young are more vulnerable to noise damage and therefore a variety of protective mechanisms exist. The quality of the sound environment of the infant is important and can be decisive for further development. It is highly desirable to detect hearing impairment as soon as possible after birth. Lack of stimulation of the auditory system, even when it functions only partially, or along a very narrow channel of communication, may lead to permanent complete loss of function of the auditory centre. But this could be prevented by early stimulation, even when it is possible only via the narrow channel of communication which fortunately is present in the great majority of cases of even severely hearing-impaired children.

Development of school screening audiometry.

It is now 50 years since serious attempts have been made to detect hearing impairment in school children, first by using the "Fading numbers gramophone audiometer" (in 1930-31) and later (in 1954) by the "Pure tone, sweep frequency, audiometric tests". There is good evidence to show (based to experience from this and many other countries) that by a properly organized screening programme, on the average, 6% of school children will be discovered to have significant hearing impairment and that without screening most of these will not be developed in this country unevenly and there are still many places where it is not practised properly or not at all. One of the reasons for this is the serious lack of understanding of the importance of screening by the authorities and, until recently, almost a complete lack of guidance by the Department of Health and Social Security. It is recommended also that systematic school-leaving audiometry should be introduced. The preventive and epidemiological significance of school leaving audiometry is stressed. Its potential importance in relation to industrial audiology is discussed. Impedance measurements are important but tests of middle-ear function should not be used as screening tests of hearing. First of all they are far too sensitive as a screening device and also it may lead to non-detection of many specific but significant sensorineural hearing losses (which are more frequent in children than generally assumed). However, it is hoped that eventually all children discovered to have a hearing loss, as a result of screening audiometry, will have a full test of middle-ear function. The two tests are complementary and not mutually exclusive.