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- Before the spike: Human oversight of artificial intelligence in EEG interpretation requires reasoning beyond recognitionPublication . Borges, Daniel Filipe; Leal, Alberto; Borges, Daniel FilipeArtificial intelligence (AI) is transforming EEGinterpretation faster than training is adapting to definewhat competent interpretation now requires. Errors arisebefore the first abnormal waveform appears, in whattrainees encounter, how they examine evidence, and howreadily a signal becomes a diagnostic label. That path isalready shortening: a deep neural network has achievedexpert- level detection of interictal epileptiform dischargesin selected settings.1 As automated recognition growsmore capable, human verification becomes more, notless, consequential. Protecting patients requires readers toreconstruct, defend, and revise the reasoning from signalto conclusion. What makes verification credible? Presenceis insufficient unless readers can explain why an output isplausible and recognize when it is not.
- Effects of caffeine on P300: A systematic review and meta-analysisPublication . Pinho, Beatriz B.; Mazer, Prune; Barroso, Beatriz; Pinto, Joana O.; Mazer, PruneCaffeine is a widely consumed psychoactive substance that stimulates the central nervous system, enhancing alertness and concentration. Its effects on brain activity can be examined using neurophysiological techniques such as event-related potentials, with emphasis on the P300 component. Caffeine appears to modulate P300 amplitude and latency, suggesting changes in processing speed and attention, although findings remain inconsistent. The objective of this work was to systematise the literature about the effects of caffeine on the amplitude and latency of the P300. A systematic review and meta-analysis of empirical studies measuring the effect of caffeine on P300 amplitude and latency was conducted, following the Preferred Reporting Items for Systematic Reviews and Meta- Analyses. Statistical analyses were performed using the meta-analysis package for R. Caffeine intake between 201 and 399 mg was associated with a significant increase in P300 amplitude across anterior, central, and posterior regions, whereas higher doses were associated with smaller effect sizes. No significant differences in P300 latency were observed between pre- and post-caffeine intake. Overall, our findings align with previous reviews showing that caffeine, as a stimulant, can modulate brain activity. The main limitation of this work is the high heterogeneity across studies. Future research directions are discussed.
- Are wearable sleep-tracking devices reliable alternatives to Polysomnography? A Systematic Review and Meta-AnalysisPublication . Agostinho, Margarida; Borges, Maria; Pereira, Telmo; Borges, Daniel Filipe; Soares, Joana Isabel; Borges, Daniel FilipePolysomnography (PSG) is the reference method for characterizing sleep architecture, but it is resource-intensive and difficult to scale for large cohort assess ments. This has increased interest in wearable devices for naturalistic sleep monitoring. This systematic review and meta-analysis evaluated how wearable sleep-tracking devices compare with laboratory PSG in healthy adults across standard sleep metrics and sleep stage durations. PubMed, Scopus, Scielo, Web of Science, and the Cochrane Library were searched following PRISMA guidelines. Eligible studies included healthy adults under going simultaneous wearable and PSG recordings. Mean differences were synthesized for total sleep time, sleep latency, sleep efficiency, wake after sleep onset, and time spent in light (N1+N2), deep (N3), and REM sleep using fixed or random effects models based on heterogeneity, with significance set at p < .01. Risk of bias and applicability were assessed using QUADAS-2. Sixteen studies met the inclusion criteria, and ten contributed to the meta- analysis. Wearable devices overestimated total sleep time and sleep efficiency and underestimated wake after sleep onset, with substantial variability between devices. No device demonstrated consistently superior performance. In individual studies, the closest agreement with PSG was observed for the Oura Ring (third generation) for sleep latency and sleep efficiency, and for selected Fitbit models for deep and REM sleep. Wearable devices provide reasonable estimates of global sleep metrics and may complement PSG for population monitoring and longitudinal self-tracking. However, variable performance, methodological heterogeneity, and risk-of-bias consid erations currently limit their use as stand-alone diagnostic tools or for detailed sleep- stage characterization.
- Hippocampal volume loss in mesial temporal lobe epilepsy: Magnitude and laterality in a meta-analysis of MRI volumetry studiesPublication . Carvalho, Ruben Lopes; Borges, Daniel Filipe; Casalta-Lopes, João; Soares, Joana Isabel; Borges, Daniel FilipeHippocampal atrophy is a defining structural feature of mesial temporal lobe epilepsy (mTLE), yet the magnitude of volume loss and the extent of contralateral involvement vary across magnetic resonance imaging (MRI) studies, limiting quantitative interpretation in clinical practice. We conducted a systematic review and meta-analysis to quantify hippocampal volume reduction in adults with mTLE and assess the consistency of contralateral changes. Following PRISMA 2020 guidelines, we searched six bibliographic databases and different trial registries. Eligible studies included adults with unilateral mTLE who underwent pre-surgical structural MRI with quantitative hippocampal volumetry, as well as healthy controls. Two reviewers independently assessed risk of bias using ROBINS-E. Random-effects meta-analyses pooled mean differences in absolute hippocampal volume (mm ; controls minus patients) for hippocampi ipsilateral and contralateral to the seizure focus. Twenty-eight studies met the inclusion criteria; 23 contributed to the meta-analysis (803 patients, 613 controls). Ipsilateral hippocampal volume was significantly reduced (mean difference 985.2 mm 759.7–1210.7; p < 0.001; I 2 3 , 95% CI =98%). Contralateral volume was also reduced (22 studies; mean difference 198.8 mm 3 , 95% CI 124.4–273.3; p < 0.001; I 2 =85%). Funnel plot inspection and Egger testing showed no evidence of small-study effects. ROBINS-E indicated low to moderate risk of bias overall. Adult mTLE shows marked ipsilateral hippocampal atrophy with a smaller, consistent contralateral reduction, consistent with partial bilateral structural involvement. Pooled estimates provide clinically interpretable reference values for quantitative MRI in presurgical evaluation, though substantial heterogeneity warrants caution.
- Comparative evaluation of artificial intelligence chatbots in answering electroencephalography-related questionsPublication . Proença, Soraia; Soares, Joana Isabel; Parra, Joana; Maia, Gisela; Leite, Juliana; Beniczky, Sándor; Jesus-Ribeiro, Joana; Henrique Maia, Gisela MariaAs large language models (LLMs) become more accessible, they may be used to explain challenging EEG concepts to nonspecialists. This study aimed to compare the accuracy, completeness, and readability of EEG-related responses from three LLM-based chatbots and to assess inter-rateragreement. One hundred questions, covering 10 EEG categories, were entered into ChatGPT, Copilot, and Gemini. Six raters from the clinical neurophysiology field (two physicians, two teachers, and two technicians) evaluated the responses. Accuracy was rated on a 6-point scale, completeness on a 3-point scale, and readability was assessed using the Automated Readability Index (ARI). We used a repeated-measures ANOVA for group differences in accuracy and readability, the intraclass correlation coefficient (ICC) for inter-raterreliability, and a two way ANOVA, with chatbot and raters as factors, for completeness. Total accuracy was significantly higher for ChatGPT (mean ± SD 4.54 ± .05) compared with Copilot (mean ± SD 4.11 ± .08) and Gemini (mean ± SD 4.16 ± .13) (p < .001). ChatGPT's lowest performance was in normal variants and patterns of uncertain significance (mean ± SD 3.10 ± .14), while Copilot and Gemini performed lowest in ictal EEG patterns (mean ± SD 2.93 ± .11 and 3.37 ± .24, respectively). Although inter-rater agreement for accuracy was excellent among physicians (ICC = .969) and teachers (ICC = .926), it was poor for technicians in several EEG categories. ChatGPT achieved significantly higher completeness scores than Copilot (p < .001) and Gemini (p = .01). ChatGPT text (ARI − mean ± SD 17.41 ± 2.38) was less readable than Copilot (ARI −mean ± SD 11.14 ± 2.60) (p < .001) and Gemini (ARI − mean ± SD 14.16 ± 3.33). Chatbots achieved relatively high accuracy, but not without flaws, emphasizing that the information provided requires verification. ChatGPT outperformed the other chatbots in accuracy and completeness, though at the expense of readability. The lower inter-rater agreement among technicians may reflect a gap in standardized training or practical experience, potentially impacting the consistency of EEG-related content assessment.
- Response to: Does reliability benefit from superior visualization of epileptiform discharges on inferior temporal electrodes?Publication . Batista, Carla; Soares, Joana Isabel; Coelho, Paulo; Ferreira, Simão; Rosenzweig, Ivana; Borges, Daniel Filipe; Borges, Daniel Filipe; Ferreira, SimãoWe thank Dr. Kleine for his thoughtful letter regarding our study and for highlighting both the anatomical rationale and the recognized clinical relevance of inferior-temporal electrodes. We welcome the opportunity to clarify specific numerical points and to provide the inter-reviewer agreement data he requested. Our study was intentionally designed as a prospective, blinded, within-subject technical validation comparing the IFCN-recommended 25-electrode 19-channel 10–20 International System (10–20 IS) in consecutive(IFCN-25) array with the conventional 19-channel 10–20 International System (10–20 IS) in consecutive adult EEGs. Importantly, it was not framed as a diagnostic or superiority trial: no external gold standard was applied, and both montages were treated methodologically as equivalent acquisition systems. The primary endpoint was patient-level detection of any abnormality (IEDs or focal slow activity) under blinded real-world conditions. In this reply, we address exclusively the point raised by Dr. Kleine concerning inter-reviewer agreement for temporal-lobe IEDs, providing the 2 × 2 tables and κ values requested. These analyses represent a clear subset of the broader dataset already published and are provided here for transparency.
- Hippotherapy improves gross motor function in children with cerebral palsy: evidence from a systematic reviewPublication . Bernardino, Inês; Borges, Daniel Filipe; Casalta Lopes, João; Soares, Joana Isabel; Borges, Daniel Filipe"Hippotherapy uses horse movement to promote physical and psychosocial rehabilitation and may benefit children with cerebral palsy (CP). Standardised instruments such as the Activity Scale for Kids-Performance (ASK©), the Gross Motor Function Classification System (GMFCS) and the Gross Motor Function Measure (GMFM) are needed to quantify effects on motor function. To systematically review the effects of hippotherapy on gross motor skills in children with CP. Although autism spectrum disorder (ASD) was included in the search strategy, no eligible ASD studies were identified. Following PRISMA guidelines, six databases (PubMed, EMBASE, Web of Science, SCOPUS, Cochrane and SciELO) were searched for English, Portuguese or Spanish studies employing ASK©, GMFCS or GMFM. Two reviewers independently screened records, extracted data and assessed risk of bias. Twenty-five studies (602 participants, mean age 7.1 years, 3–14) met inclusion criteria; all involved CP, none ASD. Interventions lasted 8–24 weeks (1–3 sessions/week). Two ASK© studies showed significant motor gains (Hedges g=0.48–0.62). GMFM was used in 22 studies; 20 reported clinically relevant improvements, particularly in dimensions D (standing) and E (walking, running, jumping). The sole GMFCS study reported no change in classification. Methodological quality was moderate, limited by small samples and lack of blinding. Hippotherapy improves gross motor function in CP, best demonstrated with GMFM. Evidence for ASD is absent, highlighting a research gap. Broader application of ASK© and GMFCS is still needed to better define benefits across neurodevelopmental disorders."
- Closing the temporal blind spot: Six additional electrodes increase patient-level EEG abnormality detection by ~12%Publication . Batista, Carla; Soares, Joana Isabel; Coelho, Paulo; Ferreira, Simão; Rosenzweig, Ivana; Borges, Daniel Filipe; Borges, Daniel Filipe; Ferreira, Simão; Soares, Joana I.To quantify the additional detection yield of the 25-channel electrodearray recommended by the International Federation of Clinical Neurophysiology(IFCN), which includes six inferior-temporal electrodes beyond the conventional 10–20 International System (IS) in identifying interictal epileptiform discharges(IEDs) and focal slow activity (SA). We analyzed 258 consecutive adult EEGs (routine or sleep-deprived; mean age, 57 ± 19 years; 55% female; 61% on anti-seizure medication). Indications were suspected epilepsy (33%) and seizure follow-up (28%). Two blinded neurophysiologists harmonized IED/SA terminology and applied the validated three-item subset of the IFCN's operational IED criteria. Each EEG was reviewed twice: first with the standard 19-electrode 10–20 system and, after a ≥ 4- week washout, with the 25-channel IFCN array. Reading lists were randomized between reviewers so that the sequence of cases differed, thereby reducing recallbias. Abnormalities were classified by type and lobe. Agreement was measured using Cohen's κ; yield gain was the detection-rate difference. Agreement ranged from substantial to almost perfect (κ = .65–.88;95% CI: .48–1.00), with disagreement rates of 1.2–7.8%. Temporal IEDs were detected more frequently with IFCN (72/71 patients) than with 10–20 (63 each), corresponding to gains of 12.5% and 11.3%, respectively. Temporal SA was also higher (98 vs. 86; +12.2% for both). Gains in extratemporal SA were smaller (10.7%and 9.5%) and differences in extratemporal IEDs were minimal (≤3.6%). Pooledacross all abnormalities, IFCN detected 183 and 182 patients versus 172 and 170with 10–20, respectively, an overall gain of 11.5%. The largest relative increase was seen in temporal IEDs, with an additional 11–12% of patients identified using the IFCN array compared with 10–20. The addition of six inferior-temporal electrodes increased the relative detection yield of EEG abnormalities by 11.5%, with the largest gains fortemporal IEDs, and required only minimal extra setup time. Although the true diagnostic accuracy of these additional detections can not be determined without an external gold standard, the findings support the routine use of the IFCN25-electrode array to address a major blind spot of the 10–20 system in adult EEGpractice.
- The left-right side-specific neuroendocrine signaling from injured brain: An organizational principlePublication . Watanabe, Hiroyuki; Henrique Maia, Gisela Maria; Kobikov, Yaromir; Nosova, Olga; Sarkisyan, Daniil; Galatenko, Vladimir; Carvalho, Liliana; Maia, Gisela H.; Lukoyanov, Nikolay; Lavrov, Igor; Ossipov, Michael H.; Hallberg, Mathias; Schouenborg, Jens; Zhang, Mengliang; Bakalkin, GeorgyA neurological dogma is that the contralateral effects of brain injury are set through crossed descending neural tracts. We have recently identified a novel topographic neuroendocrine system (T-NES) that operates via a humoral pathway and mediates the left-right side-specific effects of unilateral brain lesions. In rats with completely transected thoracic spinal cords, unilateral injury to the sensorimotor cortex produced contralateral hindlimb flexion, a proxy for neurological deficit. Here, we investigated in acute experiments whether T-NES consists of left and right counterparts and whether they differ in neural and molecular mechanisms. We demonstrated that left- and right-sided hormonal signaling is differentially blocked by the δ-, κ- and µ-opioid antagonists. Left and right neurohormonal signaling differed in targeting the afferent spinal mechanisms. Bilateral deafferentation of the lumbar spinal cord abolished the hormone-mediated effects of the left-brain injury but not the right-sided lesion. The sympathetic nervous system was ruled out as a brain-to-spinal cord-signaling pathway since hindlimb responses were induced in rats with cervical spinal cord transections that were rostral to the preganglionic sympathetic neurons. Analysis of gene–gene co-expression patterns identified the left- and right-side-specific gene co-expression networks that were coordinated via the humoral pathway across the hypothalamus and lumbar spinal cord. The coordination was ipsilateral and disrupted by brain injury. These findings suggest that T-NES is bipartite and that its left and right counterparts contribute to contralateral neurological deficits through distinct neural mechanisms, and may enable ipsilateral regulation of molecular and neural processes across distant neural areas along the neuraxis.
- The role of actigraphy in the assessment of central disorders of Hypersomnolence: A systematic review and meta-analysisPublication . Maia, Susana; Soares, Joana Isabel; Borges, Daniel Filipe; Lopes, João Casalta; Gonçalves, Marta; Borges, Daniel FilipeActigraphy provides an objective measure of sleepiness and is recommended by the American Academy of Sleep Medicine for use 7–14 days prior to multiple sleep latency testing. It plays a valuable role in the differential diagnosis of hypersomnolence. Our aim was to provide a comprehensive summary of actigraphy features in central disorders of hypersomnolence (CDH). Data were sourced from six bibliographic databases. Fixed- or random-effects models were applied to compare patients with narcolepsy type 1 (NT1) to controls. Of the 1,737 publications identified in our search, 8 studies met the inclusion criteria. The total sample consisted of 473 participants, encompassing patients with NT1, idiopathic hypersomnia (IH), hypersomnolence with normal CSF hypocretin-1 levels, Kleine–Levin syndrome (KLS), traumatic brain injury (TBI), major depressive disorder (MDD), myotonic dystrophy (MD), primary insomnia and healthy controls. Actigraphy devices varied across studies. Compared to control subjects, NT1 patients had lower total sleep time (TST), sleep efficiency and daytime motor activity, with increased wake after sleep onset, awakenings, nocturnal motor activity and longest nap duration. In KLS, TST was higher during hypersomnia episodes than during asymptomatic phases. TBI and MDD patients had a higher TST than the control group, while MD patients had a lower TST than patients with IH. Actigraphy is a valuable tool for objectively assessing sleep and can assist in detecting CDH. However, the absence of standardized guidelines limits their broader implementation in clinical practice.
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