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The evolution of free agency in professional sports leagues spans two decades from the 1972 Flood v. Kuhn decision in Major League Baseball (MLB) to the 1992 McNeil, et al. v. NFL decision in the National Football League (NFL).1 In spite of the apparent relaxation of eligibility requirements for free agency, ancillary institutional arrangements have severely limited player mobility during these two decades in all leagues but MLB. As part of a revolutionary partnership, National Basketball Association (NBA) players agreed to a league-wide payroll cap for team salaries in 1984 in exchange for a guaranteed 53 percent of NBA designated gross revenues (DGR).2 The ostensible purpose of the NBA payroll or salary cap was to control spiraling salaries and generate competitive balance within the league, but since its inception, the payroll cap has served to limit player mobility under free agency, and its effect on competitive balance is subject to question.3 Although free agency eligibility requirements have been lenient in the NFL, strict compensation rules have thwarted player movement until McNeil. In spite of free agency concessions by NFL owners following McNeil, movement of players among teams will continue to be limited under The Collective Bargaining Agreement of 1993, because of the concurrent imposition of a payroll cap at 64 percent of league-wide DGR beginning with the 1994 season.4

BACKGROUND: The influence of injuries on team performance in football has only been scarcely investigated. AIM: To study the association between injury rates and team performance in the domestic league play, and in European cups, in male professional football. METHODS: 24 football teams from nine European countries were followed prospectively for 11 seasons (2001-2012), including 155 team-seasons. Individual training and match exposure and time-loss injuries were registered. To analyse the effect of injury rates on performance, a Generalised Estimating Equation was used to fit a linear regression on team-level data. Each team's season injury rate and performance were evaluated using its own preceding season data for comparison in the analyses. RESULTS: 7792 injuries were reported during 1 026 104 exposure hours. The total injury incidence was 7.7 injuries/1000 h, injury burden 130 injury days lost/1000 h and player match availability 86%. Lower injury burden (p=0.011) and higher match availability (p=0.031) were associated with higher final league ranking. Similarly, lower injury incidence (p=0.035), lower injury burden (p<0.001) and higher match availability (p<0.001) were associated with increased points per league match. Finally, lower injury burden (p=0.043) and higher match availability (p=0.048) were associated with an increase in the Union of European Football Association (UEFA) Season Club Coefficient, reflecting success in the UEFA Champions League or Europa League. CONCLUSIONS: Injuries had a significant influence on performance in the league play and in European cups in male professional football. The findings stress the importance of injury prevention to increase a team's chances of success.

Professional team sports leagues provide insight into the problems facing the management of functioning cartels. This paper provides an analysis of the incentives and outcomes inherent in the management of professional team sports cartels. Except for revenue sharing and salary caps, league cartel management outcomes are consistent with league-wide revenue maximization and have no impact on competitive balance. However, there are predictable impacts on the profitability of strong- and weak-drawing teams within the league. While providing an analytical review of the literature, the work here also yields new results concerning salary caps, local TV revenue sharing, and the behavior of cartel managers in the face of rival leagues.

While studies have investigated speed and change of direction speed in rugby league players, no study has investigated the reactive agility of these athletes. In addition, the relationship among speed, change of direction speed, and reactive agility within the specific context of rugby league has not been determined. With this in mind, the purpose of this study was to investigate a wide range of speed, change of direction speed, and reactive agility tests commonly used by rugby league coaches to determine which, if any tests discriminated higher and lesser skilled players, and to investigate the relationship among speed, change of direction speed, and reactive agility in these athletes. Forty-two rugby league players completed tests of speed (5 m, 10 m, and 20 m sprint), change of direction speed ('L' run, 505 test, and modified 505 test), and reactive agility. The validity of the tests to discriminate higher and lesser skilled competitors was evaluated by testing first grade (N = 12) and second grade (N = 30) players. First grade players had faster speed, and movement and decision times on the reactive agility test than second grade players. No significant differences were detected between first and second grade players for change of direction speed. While movement times on the reactive agility test were significantly related to 10 m and 20 m sprint times and change of direction speed, no significant relationships were detected among measures of decision time and response accuracy during the reactive agility test and measures of linear speed and change of direction speed. These findings question the validity of preplanned change of direction speed tests for discriminating higher and lesser skilled rugby league players, while also highlighting the contribution of perceptual skill to agility in these athletes.

The 2017 International League Against Epilepsy classification has defined a three-tier system with epilepsy syndrome identification at the third level. Although a syndrome cannot be determined in all children with epilepsy, identification of a specific syndrome provides guidance on management and prognosis. In this paper, we describe the childhood onset epilepsy syndromes, most of which have both mandatory seizure type(s) and interictal electroencephalographic (EEG) features. Based on the 2017 Classification of Seizures and Epilepsies, some syndrome names have been updated using terms directly describing the seizure semiology. Epilepsy syndromes beginning in childhood have been divided into three categories: (1) self-limited focal epilepsies, comprising four syndromes: self-limited epilepsy with centrotemporal spikes, self-limited epilepsy with autonomic seizures, childhood occipital visual epilepsy, and photosensitive occipital lobe epilepsy; (2) generalized epilepsies, comprising three syndromes: childhood absence epilepsy, epilepsy with myoclonic absence, and epilepsy with eyelid myoclonia; and (3) developmental and/or epileptic encephalopathies, comprising five syndromes: epilepsy with myoclonic-atonic seizures, Lennox-Gastaut syndrome, developmental and/or epileptic encephalopathy with spike-and-wave activation in sleep, hemiconvulsion-hemiplegia-epilepsy syndrome, and febrile infection-related epilepsy syndrome. We define each, highlighting the mandatory seizure(s), EEG features, phenotypic variations, and findings from key investigations.

OBJECTIVE: We present the results of the autopsy of a retired professional football player that revealed neuropathological changes consistent with long-term repetitive concussive brain injury. This case draws attention to the need for further studies in the cohort of retired National Football League players to elucidate the neuropathological sequelae of repeated mild traumatic brain injury in professional football. METHODS: The patient's premortem medical history included symptoms of cognitive impairment, a mood disorder, and parkinsonian symptoms. There was no family history of Alzheimer's disease or any other head trauma outside football. A complete autopsy with a comprehensive neuropathological examination was performed on the retired National Football League player approximately 12 years after retirement. He died suddenly as a result of coronary atherosclerotic disease. Studies included determination of apolipoprotein E genotype. RESULTS: Autopsy confirmed the presence of coronary atherosclerotic disease with dilated cardiomyopathy. The brain demonstrated no cortical atrophy, cortical contusion, hemorrhage, or infarcts. The substantia nigra revealed mild pallor with mild dropout of pigmented neurons. There was mild neuronal dropout in the frontal, parietal, and temporal neocortex. Chronic traumatic encephalopathy was evident with many diffuse amyloid plaques as well as sparse neurofibrillary tangles and tau-positive neuritic threads in neocortical areas. There were no neurofibrillary tangles or neuropil threads in the hippocampus or entorhinal cortex. Lewy bodies were absent. The apolipoprotein E genotype was E3/E3. CONCLUSION: This case highlights potential long-term neurodegenerative outcomes in retired professional National Football League players subjected to repeated mild traumatic brain injury. The prevalence and pathoetiological mechanisms of these possible adverse long-term outcomes and their relation to duration of years of playing football have not been sufficiently studied. We recommend comprehensive clinical and forensic approaches to understand and further elucidate this emergent professional sport hazard.

BACKGROUND: Little is known about the injury rates in Major League Baseball (MLB) players, as a formal injury surveillance system does not exist. The goal of this study was to characterize the epidemiology of MLB injuries over a 7-year period. HYPOTHESIS: Injuries in MLB would be common. STUDY DESIGN: Descriptive epidemiologic study. METHODS: The authors analyzed the MLB disabled list data from 2002 through 2008. Injuries were analyzed for differences between seasons, as well as during seasons on a monthly basis. The injuries were categorized by major anatomic zones and then further stratified based on injury type. Position-specific subanalyses for pitcher and position players were performed. RESULTS: From the 2002 season through the 2008 season, an average of 438.9 players per year were placed on the disabled list, for a rate of 3.61 per 1000 athlete-exposures. There was a significant 37% increase in injuries between 2005 and 2008. The highest injury rate during the season was during the month of April (5.73/1000 exposures) and the lowest in September (0.54/1000 exposures). No differences were noted in the injury rates between the National League and the American League (incidence rate ratio [IRR] = 1.06; 95% confidence interval [CI] = 0.98, 1.15). Pitchers experienced 34% higher incidence rates for injury compared with fielders during the study period (IRR = 1.34; 95% CI = 1.25, 1.44). Among all player injuries, upper extremity injuries accounted for 51.4% while lower extremity injuries accounted for 30.6%. Injuries to the spine and core musculature accounted for 11.7% while other injuries and illnesses were 6.3% of the total disabled list entries. There was a significant association between position played and anatomic region injured (P < .001), with pitchers experiencing a significantly greater proportion of injuries to the upper extremity (67.0%; 95% CI = 63.1%, 70.9%) compared with fielders (32.1%; 95% CI = 29.1%, 35.1%). Conversely, fielders experienced a significantly greater proportion of injuries to the lower extremity (47.5%; 95% CI = 43.8%, 51.1%) compared with pitchers (16.9%; 95% CI = 14.9%, 18.8%). The mean number of days on the disabled list was 56.6. Overall, a greater proportion of disability days were experienced by pitchers (62.4%; 95% CI = 62.0%, 62.8%; P < .001) compared with fielders (37.6%; 95% CI = 37.3%, 37.9%). CONCLUSION: Injuries in MLB resulting in disabled list designation are common. Upper extremity injuries were predominant in pitchers, while lower extremity injuries are more common in position players. These data may be used in the development of a formal MLB injury database, as well as in the development and implementation of specific preseason training and in-season conditioning for injury prevention.

OBJECTIVE: The 1987 American College of Rheumatology (ACR; formerly, the American Rheumatism Association) classification criteria for rheumatoid arthritis (RA) have been criticized for their lack of sensitivity in early disease. This work was undertaken to develop new classification criteria for RA. METHODS: A joint working group from the ACR and the European League Against Rheumatism developed, in 3 phases, a new approach to classifying RA. The work focused on identifying, among patients newly presenting with undifferentiated inflammatory synovitis, factors that best discriminated between those who were and those who were not at high risk for persistent and/or erosive disease--this being the appropriate current paradigm underlying the disease construct "rheumatoid arthritis." RESULTS: In the new criteria set, classification as "definite RA" is based on the confirmed presence of synovitis in at least 1 joint, absence of an alternative diagnosis that better explains the synovitis, and achievement of a total score of 6 or greater (of a possible 10) from the individual scores in 4 domains: number and site of involved joints (score range 0-5), serologic abnormality (score range 0-3), elevated acute-phase response (score range 0-1), and symptom duration (2 levels; range 0-1). CONCLUSION: This new classification system redefines the current paradigm of RA by focusing on features at earlier stages of disease that are associated with persistent and/or erosive disease, rather than defining the disease by its late-stage features. This will refocus attention on the important need for earlier diagnosis and institution of effective disease-suppressing therapy to prevent or minimize the occurrence of the undesirable sequelae that currently comprise the paradigm underlying the disease construct "rheumatoid arthritis."

OBJECTIVE: To validate the European League Against Rheumatism (EULAR), the American College of Rheumatology (ACR), and the World Health Organization (WHO)/International League Against Rheumatism (ILAR) response criteria for rheumatoid arthritis (RA). METHODS: EULAR response criteria were developed combining change from baseline and level of disease activity attained during follow up. In a trial comparing hydroxychloroquine and sulfasalazine, we studied construct (radiographic progression), criterion (functional capacity), and discriminant validity. RESULTS: EULAR response criteria had good construct, criterion, and discriminant validity, ACR and WHO/ILAR criteria showed only good criterion validity. CONCLUSION: EULAR response criteria showed better construct and discriminant validity than did the ACR and the WHO/ILAR response criteria for RA.

This article examines the role and usefulness of league tables that are increasingly used to measure and compare the performance of tertiary education institutions. The article begins with a general overview and a typology of league tables. It continues with a discussion of the controversies they have generated, including the basis and the range of criticism they have invited, the merit of indicators they use as measures of quality, and the potential conditions that place universities at an advantage or a disadvantage in ranking exercises. The paper ends with a discussion of implications of league tables for national policies and institutional practices both in the developing world and in industrial countries.

The aims of this study were to (1) determine the activity profiles of a large sample of English FA Premier League soccer players and (2) examine high-intensity running during elite-standard soccer matches for players in various playing positions. Twenty-eight English FA Premier League games were analysed during the 2005-2006 competitive season (n=370), using a multi-camera computerised tracking system. During a typical match, wide midfielders (3138 m, s=565) covered a greater distance in high-intensity running than central midfielders (2825 m, s= 73, P=0.04), full-backs (2605 m, s=387, P < 0.01), attackers (2341 m, s=575, P < 0.01), and central defenders (1834 m, s=256, P < 0.01). In the last 15 min of a game, high-intensity running distance was approximately 20% less than in the first 15-min period for wide midfielders (467 m, s=104 vs. 589 m, s=134, P < 0.01), central midfielders (429 m, s=106 vs. 534 m, s=99, P < 0.01), full-backs (389 m, s=95 vs. 481 m, s=114, P < 0.01), attackers (348 m, s=105 vs. 438 m, s=129, P < 0.01), and central defenders (276 m, s=93 vs. 344 m, s=80, P < 0.01). There was a similar distance deficit for high-intensity running with (148 m, s=78 vs. 193 m, s=96, P < 0.01) and without ball possession (229 m, s=85 vs. 278 m, s=97, P < 0.01) between the last 15-min and first 15-min period of the game. Mean recovery time between very high-intensity running bouts was 72 s (s=28), with a 28% longer recovery time during the last 15 min than the first 15 min of the game (83 s, s=26 vs. 65 s, s=20, P < 0.01). The decline in high-intensity running immediately after the most intense 5-min period was more evident in attackers (216 m, s=50 vs. 113 m, s=47, P < 0.01) and central defenders (182 m, s=26 vs. 96 m, s=39, P < 0.01). The results suggest that high-intensity running with and without ball possession is reduced during various phases of elite-standard soccer matches and the activity profiles and fatigue patterns vary among playing positions. The current findings provide valuable information about the high-intensity running patterns of a large sample of elite-standard soccer players, which could be useful in the development and prescription of specific training regimes.

The aim of the present investigation was to provide a detailed analysis of the high intensity running activity completed by elite soccer players during match-play. A further aim of the study was to evaluate the importance of high intensity running activity to overall team success. Observations on individual match performance measures were undertaken on 563 outfield players (median of 8 games per player; range=1-57) competing in the English Premier League from 2003/2004 to 2005/2006 using a computerised tracking system (Prozone, Leeds, England). High intensity activities selected for analysis included total high intensity running distance (THIR), total sprint distance (TSD) and the number and type of sprints undertaken. Total high intensity running distance in possession and without possession of the ball was also analysed. The THIR was dependant upon playing position with wide midfield (1,049+/-106 m) and central defenders (681+/-128 m) completing the highest and lowest distance respectively (p<0.001). High intensity activity was also related to team success with teams finishing in the bottom five (919+/-128 m) and middle ten (917+/-143 m) league positions completing significantly more THIR compared with teams in the top five (885+/-113 m) (p=0.003). The THIR and TSD also significantly declined during the 2nd half with the greatest decrements observed in wide midfield and attacking players (p<0.05). Both positional differences in high intensity activity and the observed change in activity throughout the game were also influenced by team success (p<0.05). The results of the present study indicate that high intensity activity in elite soccer match-play is influenced by both playing position and previous activity in the game. These activity patterns are also dependant upon success of the team. This may indicate that overall technical and tactical effectiveness of the team rather than high levels of physical performance per se are more important in determining success in soccer.

This study examined the evolution of physical and technical soccer performance across a 7-season period in the English Premier League. Match performance observations (n=14 700) were analysed for emergent trends. Total distance covered during a match was ~2% lower in 2006-07 compared to 2012-13. Across 7 seasons, high-intensity running distance and actions increased by ~30% (890±299 vs. 1 151±337 m, p<0.001; ES: 0.82) and ~50% (118±36 vs. 176±46, p<0.001; ES: 1.41), respectively. Sprint distance and number of sprints increased by ~35% (232±114 vs. 350±139 m, p<0.001; ES: 0.93) and ~85% (31±14 vs. 57±20, p<0.001; ES: 1.46), respectively. Mean sprint distance was shorter in 2012-13 compared to 2006-07 (5.9±0.8 vs. 6.9±1.3 m, p<0.001; ES: 0.91), with the proportion of explosive sprints increasing (34±11 vs. 47±9%, p<0.001; ES: 1.31). Players performed more passes (35±17 vs. 25±13, p<0.001; ES: 0.66) and successful passes (83±10% vs. 76±13%, p<0.001; ES: 0.60) in 2012-13 compared to 2006-07. Whereas the number of short and medium passes increased across time (p<0.001; ES>0.6), the number of long passes varied little (p<0.001; ES: 0.11). This data demonstrates evolution of physical and technical parameters in the English Premier League, and could be used to aid talent identification, training and conditioning preparation.

The International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE) have come to consensus definitions for the terms epileptic seizure and epilepsy. An epileptic seizure is a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition. The definition of epilepsy requires the occurrence of at least one epileptic seizure.

OBJECTIVE: The 1980 American College of Rheumatology (ACR) classification criteria for systemic sclerosis (SSc) lack sensitivity for early SSc and limited cutaneous SSc. The present work, by a joint committee of the ACR and the European League Against Rheumatism (EULAR), was undertaken for the purpose of developing new classification criteria for SSc. METHODS: Using consensus methods, 23 candidate items were arranged in a multicriteria additive point system with a threshold to classify cases as SSc. The classification system was reduced by clustering items and simplifying weights. The system was tested by 1) determining specificity and sensitivity in SSc cases and controls with scleroderma-like disorders, and 2) validating against the combined view of a group of experts on a set of cases with or without SSc. RESULTS: It was determined that skin thickening of the fingers extending proximal to the metacarpophalangeal joints is sufficient for the patient to be classified as having SSc; if that is not present, 7 additive items apply, with varying weights for each: skin thickening of the fingers, fingertip lesions, telangiectasia, abnormal nailfold capillaries, interstitial lung disease or pulmonary arterial hypertension, Raynaud's phenomenon, and SSc-related autoantibodies. Sensitivity and specificity in the validation sample were, respectively, 0.91 and 0.92 for the new classification criteria and 0.75 and 0.72 for the 1980 ACR classification criteria. All selected cases were classified in accordance with consensus-based expert opinion. All cases classified as SSc according to the 1980 ACR criteria were classified as SSc with the new criteria, and several additional cases were now considered to be SSc. CONCLUSION: The ACR/EULAR classification criteria for SSc performed better than the 1980 ACR criteria for SSc and should allow for more patients to be classified correctly as having the disease.

The International League Against Epilepsy (ILAE) presents a revised operational classification of seizure types. The purpose of such a revision is to recognize that some seizure types can have either a focal or generalized onset, to allow classification when the onset is unobserved, to include some missing seizure types, and to adopt more transparent names. Because current knowledge is insufficient to form a scientifically based classification, the 2017 Classification is operational (practical) and based on the 1981 Classification, extended in 2010. Changes include the following: (1) "partial" becomes "focal"; (2) awareness is used as a classifier of focal seizures; (3) the terms dyscognitive, simple partial, complex partial, psychic, and secondarily generalized are eliminated; (4) new focal seizure types include automatisms, behavior arrest, hyperkinetic, autonomic, cognitive, and emotional; (5) atonic, clonic, epileptic spasms, myoclonic, and tonic seizures can be of either focal or generalized onset; (6) focal to bilateral tonic-clonic seizure replaces secondarily generalized seizure; (7) new generalized seizure types are absence with eyelid myoclonia, myoclonic absence, myoclonic-atonic, myoclonic-tonic-clonic; and (8) seizures of unknown onset may have features that can still be classified. The new classification does not represent a fundamental change, but allows greater flexibility and transparency in naming seizure types.

OBJECTIVE: To develop new classification criteria for systemic lupus erythematosus (SLE) jointly supported by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR). METHODS: This international initiative had four phases. 1) Evaluation of antinuclear antibody (ANA) as an entry criterion through systematic review and meta-regression of the literature and criteria generation through an international Delphi exercise, an early patient cohort, and a patient survey. 2) Criteria reduction by Delphi and nominal group technique exercises. 3) Criteria definition and weighting based on criterion performance and on results of a multi-criteria decision analysis. 4) Refinement of weights and threshold scores in a new derivation cohort of 1,001 subjects and validation compared with previous criteria in a new validation cohort of 1,270 subjects. RESULTS: The 2019 EULAR/ACR classification criteria for SLE include positive ANA at least once as obligatory entry criterion; followed by additive weighted criteria grouped in 7 clinical (constitutional, hematologic, neuropsychiatric, mucocutaneous, serosal, musculoskeletal, renal) and 3 immunologic (antiphospholipid antibodies, complement proteins, SLE-specific antibodies) domains, and weighted from 2 to 10. Patients accumulating ≥10 points are classified. In the validation cohort, the new criteria had a sensitivity of 96.1% and specificity of 93.4%, compared with 82.8% sensitivity and 93.4% specificity of the ACR 1997 and 96.7% sensitivity and 83.7% specificity of the Systemic Lupus International Collaborating Clinics 2012 criteria. CONCLUSION: These new classification criteria were developed using rigorous methodology with multidisciplinary and international input, and have excellent sensitivity and specificity. Use of ANA entry criterion, hierarchically clustered, and weighted criteria reflects current thinking about SLE and provides an improved foundation for SLE research.

To the Editor: Fisher et al. (1) state, “Little common agreement exists on the definition of the terms seizure and epilepsy,” and they propose ILAE-endorsed definitions for these terms. Although their proposed definition of “seizure” is consistent with that which has been in use throughout the field for decades, their proposed definition of epilepsy is not. Fisher and colleagues (1) propose the following definition of epilepsy: “Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition.” The definition of epilepsy in Fisher's Table 1 (1) requires the occurrence of at least one epileptic seizure but not that the seizure be unprovoked. Although it may be helpful to consider diverse conditions (febrile seizure, acute symptomatic seizure, single unprovoked seizure, and epilepsy) within the context of studying the seizure disorders, it is not helpful to consider all of these conditions as epilepsy. The more restrictive definition of epilepsy (recurrent unprovoked seizures), adopted by the ILAE Commission on Epidemiology and Prognosis (2), is related to therapeutic, management, and counseling approaches and supported by epidemiologic studies of seizure disorders. Furthermore, this definition has been largely adopted in clinical practice and was instrumental in developing practice guidelines (3). The failure to clarify the concept of “enduring” is a problem with the proposed definition, and it is unclear how Fisher et al. (1) would define or make operational this term. Making operational “enduring alteration of the brain that increases the likelihood of future seizures (1)” would require a list of indicators of such an alteration. These, in turn, would have to be qualified and changed as knowledge increases. For clinical and scientific purposes, the operational criteria must be simple and robust. We suggest instead that the best way to know whether a person has an enduring alteration of the brain that increases the likelihood of future unprovoked seizures after a first seizure is the occurrence of a second unprovoked seizure. This new definition would reclassify many situations previously excluded from the term epilepsy in recent studies. Examples include a single provoked seizure secondary to a neurologic insult (e.g., stroke), a single provoked or unprovoked seizure in someone with depression or migraine, and a febrile seizure in a child with cerebral palsy, with an epileptiform EEG, or with febrile seizure recurrence. The all-inclusive definition proposed by Fisher et al. (1) is consistent with use before the emergence of the epidemiologic studies of seizure disorders and epilepsy over the past 60-year period. The exclusion of these conditions from the diagnosis of epilepsy was based on large, carefully conducted clinical and population-based studies. Most acute symptomatic seizures would be recategorized as epilepsy under the definition proposed by Fisher et al. (1). Acute symptomatic seizures have been defined as seizures in close temporal association with a transient CNS insult and presumed to be an acute manifestation of the insult. Although the risk of developing unprovoked seizure is higher in people with acute symptomatic seizures, in most, later seizures do not develop. Although the incidence of acute symptomatic seizure is similar to the incidence of epilepsy, the high early mortality and the protective effect of anticonvulsants on the development of acute symptomatic seizures dramatically distinguish this category of seizures from epilepsy. By the proposed definition (1), many children with febrile seizures, the most common convulsive disorder, would be reclassified as having epilepsy. This would be true for children with developmental delay, neurologic abnormalities, epileptiform EEG abnormalities, complex febrile seizure, and recurrent febrile seizure. Regardless of the presence of such factors, in most children with febrile seizure, later unprovoked seizures do not develop (4,5). Restricting the diagnostic labeling of epilepsy to the few who truly have recurrent unprovoked seizures would seem prudent. It is useful to study single unprovoked seizures within the context of epilepsy to better understand the underlying processes to increase the risk for the development of recurrent unprovoked seizures. Contrary to the proposed definition (1), the epidemiologic data on recurrence risks support separating single unprovoked seizure from recurrent unprovoked seizures (i.e., epilepsy). The recurrence risk is lower after a first unprovoked seizure (typically <50%) than the recurrence risk after a second unprovoked seizure for both children and adults (6,7), suggesting that the recurrence of unprovoked seizure or lack thereof delineates different entities. A major problem with the proposed definition (1), particularly for those with single seizure and with febrile seizure, is that labeling patients with only a single seizure as having epilepsy, when many will never experience another seizure, will cause unnecessary use of anticonvulsant drugs, increase stigma, and result in social and occupational limitation. This does not serve the needs of these patients and is inconsistent with epidemiologic data. The inclusion of associated conditions in the proposed definition (1) raises concerns on several levels. Although general agreement may exist that “for some people with epilepsy, behavioral disturbances such as interictal and postictal cognitive problems, can be part of the epileptic condition (1),” the definition as written seems to require these disturbances for the condition to be epilepsy. Thus a person with multiple unprovoked seizures and a likelihood of more would not have epilepsy by the definition of Fisher et al. unless one of these associated conditions also was present. This aspect of the proposal creates a new unnamed category that may be quite large—people who clearly have recurrent unprovoked seizures, but lack documentation of associated conditions. Even if the proposed behavioral component is accepted as an essential ingredient in the definition of epilepsy, it is unclear how this would be made operational. Other consequences ensue from this definition. The incidence of “epilepsy” will increase at least threefold, and the increase in prevalence will be greater, particularly in developing countries, which may provide political leverage. Undesired consequences of use of this definition will be the invalidation of prognostic studies, including those of mortality, long-term prognosis for seizure remission, and response to initial therapy. Contrary to the proposal of Fisher et al. (1), widespread acceptance of and agreement over the definitions of seizures and epilepsy are in general use in the field. We fail to see the advantages of the proposed definitions to the individual patient, to epilepsy as a condition, or to the study of epilepsy and the convulsive disorders. Maintaining a common language has been acknowledged in several ILAE Commission and Task Force reports as a prerequisite to communication and comparability of research from different groups. In addition, the medical, social, and emotional implications of epilepsy and seizures speak in favor of a separation between acute symptomatic seizures, febrile seizures, and unprovoked seizures and, for those with unprovoked seizures, between single and repeated episodes. To this end, the current definitions have been most successful. They are based on a process similar to the evidence-based approaches used for evaluating therapies and therapeutic policies. They may be subject to revision as new information comes to light, but this process should be respected. It does not appear that proposed definitions advance the field in any way.