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The importance of people compliance (social desirability bias) in the assessment of epilepsy prevalence in rural areas of developing countries. Results of the Atahualpa Project

Epilepsia - Mon, 10/24/2016 - 04:30

Epilepsy is a major health issue in rural areas of developing countries. However, heterogeneity of epilepsy prevalence in different studies precludes assessment of the magnitude of the problem. Using similar protocols, two population-based surveys were conducted 12 years apart (2003 and 2015) in a rural Ecuadorian village (Atahualpa). The only difference was a higher people compliance with interviewers during the second survey. Epilepsy prevalence in the 2003 survey was 13.5 per 1,000 (18/1,332) in villagers aged ≥20 years. This rate increased to 26.8 per 1,000 (41/1,530) in the 2015 survey. Thirty-three persons with epilepsy detected during the second survey lived in the village in 2003; six of them had seizures starting after 2003. Of the remaining 27 cases, 13 (48%) denied their problem during the first survey. Further interview revealed that denial was related to lack of confidence with unacquainted field personnel. Social Desirability Scale-17 scores were lower in those who admitted having epilepsy than in those who denied their condition (p = 0.048). Lack of confidence with interviewers and a social desirability bias account for a sizable proportion of epilepsy denial in the study population, and may explain heterogeneity of epilepsy prevalence reported in studies conducted in poor rural settings.

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Restricting Calorie Intake May be Beneficial in Epilepsy

Epilepsy Research - Fri, 10/21/2016 - 13:24

Restricting calorie intake could protect brain cells from damage and have a beneficial effect in epilepsy, according to a rodent study published in the scientific journal, Aging Cell.

Several studies on animal models have suggested a link between calorie intake and a longer lifespan, however the molecular mechanism of how restricting calorie intake can protect against disease is not well understood.

Now, researchers at the Center for Research on Redox Processes in Biomedicine (Redoxoma), in Brazil, have shown that reducing calorie intake by 40% can increase the amount of calcium that is retained in mitochondria (the cell’s powerhouses) when calcium levels inside cells are abnormally high. This could help prevent neuronal death associated with epilepsy and other neurological conditions.

First Author, Dr Ignacio Amigo, said: “More than promoting the advantages of eating frugally, we aim to understand the mechanisms that make not over consuming calories better for health. This can point to new targets for the development of drugs against various diseases.”

The team gave one group of rodents food and water ad libitum (meaning that they could eat and drink as much as they wanted) for 14 weeks, and they restricted the food intake of another group of animals by 40%. The first group of animals became overweight at the end of the 14 weeks period, whilst those in the second group did not.

The animals were then injected with a substance called kainic acid, which promotes calcium influx into neurons and is used to induce seizures. When they isolated the mitochondria from the brain cells of the animals, the researchers saw that there was a higher level of mitochondrial calcium uptake in the mitochondria of the animals whose diet was restricted.

It is known that calcium plays an important role in the communication between nerve cells. Conditions like epilepsy can cause an excessive release of calcium into neurons due to the over activation of receptors called glutamate receptors, which can damage and even kill the neurons. Previous research has shown that an increased mitochondrial calcium uptake can have a protective effect against this calcium influx.

The researchers also observed that the activity of antioxidant enzymes was increased in the mitochondria of the diet-restricted animals, suggesting an enhanced capacity to manage oxidative stress and therefore protect against neurological conditions.

According to the team, the proteins whose activity has been altered by a reduced calorie intake could potentially be targeted to develop new therapies for conditions such as epilepsy, where excessive calcium influx leads to neuronal death.

Author: Dr Özge Özkaya




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Distinct Brain Activity in Between Seizures Can Affect Thinking Ability in Adults with Epilepsy

Epilepsy Research - Thu, 10/20/2016 - 09:40

Interictal epileptiform discharges (IEDs) – distinct patterns of brain activity that happen in between epileptic seizures – are associated with poorer cognitive performance (thinking ability) in adults with epilepsy, according to a study published in the scientific journal, Epilepsy Research.

Therefore, reducing IEDs could improve cognitive performance and have positive effects on the quality of life of people with epilepsy.

The study, led by Dr Sheng-Di Chen, at Ruijin Hospital, in Shanghai, recruited 167 seizure-free adults who underwent electroencephalography (EEG) testing and extensive cognitive evaluations. The data were then analysed for links between IEDs (shown on EEG) and cognitive performance.

The results showed that people with general IEDs achieved lower scores in cognitive tests. These scores were associated with lower verbal fluency and language scores.

Further analysis showed that sleep-phase IEDs were also associated with lower performance in cognitive tests. Moreover, non-rapid eye movement IEDs were linked with difficulties in processing and interpreting visual information about where objects are in space as well as with memory. IEDs whilst awake were associated with poorer performance in trial making test, which measures visual search, scanning and processing speed, as well as mental flexibility and executive functioning (the ability to plan, organize and complete tasks).

The authors conclude: “Cognitive performance is associated with IEDs in adult epilepsy patients, and could serve as a springboard for further research into reducing IEDs to bring about better cognitive performance.”

Difficulties with thinking are one of the major consequences of epilepsy, and they have been shown to reduce quality of life. It is recognised that IEDs are associated with poorer cognitive performance in children, but no such association has previously been shown in adults with epilepsy.

Author: Dr Özge Özkaya

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Symptomatic and presumed symptomatic focal epilepsies in childhood: An observational, prospective study

Epilepsia - Thu, 10/20/2016 - 05:11
Summary Objective

To describe the clinical, neuropsychological, and psychopathologic features of a cohort of children with a new diagnosis of symptomatic or presumed symptomatic focal epilepsy at time of recruitment and through the first month. The selected population will be followed for 2–5 years after enrollment to investigate the epilepsy course and identify early predictors of drug resistance.


In this observational, multicenter, nationwide study, children (age 1 month–12.9 years) with a new diagnosis of symptomatic or presumed symptomatic focal epilepsy were consecutively enrolled in 15 Italian tertiary childhood epilepsy centers. Inclusion criteria were as follows: (1) diagnosis of symptomatic focal epilepsy due to acquired and developmental etiologies, and presumed symptomatic focal epilepsy; (2) age at diagnosis older than 1 month and <13 years; and (3) written informed consent. Children were subdivided into three groups: ≤3 years, >3 to 6 years, and >6 years. Clinical, electroencephalography (EEG), neuroimaging, and neuropsychological variables were identified for statistical analyses.


Two hundred fifty-nine children were enrolled (116 female and 143 male). Median age: 4.4 years (range 1 month–12.9 years); 46.0% (n = 119) of children were younger than 3 years, 24% (61) from 3 to 6 years of age, and 30% (79) older than 6 years. Neurologic examination findings were normal in 71.8%. Brain magnetic resonance imaging (MRI) was abnormal in 59.9%. Children age ≤3 years experienced the highest seizure frequency in the first month after recruitment (p < 0.0001). Monotherapy in the first month was used in 67.2%. Cognitive tests at baseline revealed abnormal scores in 30%; behavioral problems were present in 21%. At multivariate analysis, higher chances to exhibit more than five seizures in the first month after epilepsy onset was confirmed for younger children and those with temporal lobe epilepsy.


In this prospective cohort study, an extensive characterization of epilepsy onset in children with symptomatic or presumed symptomatic focal epilepsies is reported in relation to the age group and the localization of the epileptogenic zone.

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The Generation of Epileptiform Discharges May Not Be Random and May Be Controlled by Biological Clocks

Epilepsy Research - Wed, 10/19/2016 - 07:40

A study published in the journal, Epilepsy and Behavior, suggests that the generation of epileptiform discharges (EDs – distinct patterns of brain activity that can arise in between epileptic seizures) is not a random process but the result of complex interactions controlling sleep-wake cycles. It also highlights that the majority of EDs may, in fact, occur during sleep.

On the basis of their findings, the investigators propose that 24-hour electroencephalography (EEG) recordings that capture natural sleep may be more useful than routine EEG in diagnosing genetic generalised epilepsy.

During the study, the team, led by Dr Wendyl D’Souza, at the University of Melbourne, studied 24-hour EEG recordings from people diagnosed with genetic generalised epilepsy. They analysed almost 7,000 EDs within 105 abnormal EEGs.

The researchers found that there were significant changes in ED counts across the 24-hour period, and that the distribution was largely influenced by the person’s state of arousal. The majority of EDs (67%) occurred during non-REM sleep, peaking from 23:00 through to 07:00, and in 24 people (23%), EDs occurred only in sleep. Overall just 33% of the EDs occurred during wakefulness. In-depth analysis of the EEGs revealed a difference in the nature of the EDs arising in non-REM sleep and in wakefulness.

Dr D’Souza and colleagues conclude that EDs are generated as a result of complex interactions among biorhythms. “A deeper understanding of those biorhythms including the intrinsic circadian clock of epilepsy is likely to enhance our knowledge in diagnosis, seizure prediction methods and treatment,” they write.

Author: Dr Özge Özkaya

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Women with Epilepsy who are Overweight Should Be Closely Monitored in Pregnancy to Avoid Complications

Epilepsy Research - Tue, 10/18/2016 - 09:19

Women with epilepsy who are overweight are at a higher risk of developing complications during pregnancy and delivery, according to a new study published in the scientific journal, Epilepsia.

The authors state that these women should be regarded as a high-risk group, and that they should be referred to a nutritionist both before an antiepileptic drug (AED) is started and when a pregnancy is planned.

For the study, which was based on the Norwegian Mother and Child Cohort Study linked to the Medical Birth Registry of Norway, researchers led by Dr Marte Bjørk, at the University of Bergen, analysed the birth records of almost 100,000 pregnant women across Norway, from between 1999 and 2008.

A total of 706 women had a diagnosis of epilepsy and, among them, 259 were classed as overweight (having a body mass index (BMI) of 25 or more) and 416 were classed as ‘normal’ weight. Of the women who did not have epilepsy, 30,516 were overweight and 67,977 were normal weight.

The researchers noted from their subjects that women with epilepsy were more likely to be overweight than those without epilepsy. Looking specifically at the women who were overweight, they discovered that those with epilepsy had an increased risk of many birth complications (e.g. needing a caesarean section, having excessive bleeding during delivery, having a smaller than normal baby and developing depression and anxiety) compared to those without epilepsy.

The team then compared women with epilepsy who were overweight and normal weight. Here, they found that those who were overweight had a greater risk of needing a caesarean section, of having high blood pressure linked to pregnancy and of preeclampsia. The babies of the women with epilepsy who were overweight also had a higher risk of being transferred to the neonatal ward.

The authors recommend that blood sugar and signs of preeclampsia, anxiety and depression be more closely monitored in women with epilepsy who are overweight. They also suggest that additional ultrasounds should be considered for these women, to assess any growth abnormalities in the baby.

Author: Dr Özge Özkaya

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Costs and cost-driving factors for acute treatment of adults with status epilepticus: A multicenter cohort study from Germany

Epilepsia - Tue, 10/18/2016 - 07:30
Summary Objective

To provide first data on inpatient costs and cost-driving factors due to nonrefractory status epilepticus (NSE), refractory status epilepticus (RSE), and super-refractory status epilepticus (SRSE).


In 2013 and 2014, all adult patients treated due to status epilepticus (SE) at the university hospitals in Frankfurt, Greifswald, and Marburg were analyzed for healthcare utilization.


We evaluated 341 admissions in 316 patients (65.7 ± [standard deviation]18.2 years; 135 male) treated for SE. Mean costs of hospital treatment were €14,946 (median €5,278, range €776–€152,911, €787 per treatment day) per patient per admission, with a mean length of stay (LOS) of 19.0 days (median 14.0, range 1–118). Course of SE had a significant impact on mean costs, with €8,314 in NSE (n = 137, median €4,597, €687 per treatment day, 22.3% of total inpatient costs due to SE), €13,399 in RSE (n = 171, median €7,203, €638/day, 45.0% of total costs, p < 0.001), and €50,488 in SRSE (n = 33, median €46,223, €1,365/day, 32.7% of total costs, p < 0.001). Independent cost-driving factors were SRSE, ventilation, and LOS of >14 days. Overall mortality at discharge was 14.4% and significantly higher in RSE/SRSE (20.1%) than in NSE (5.8%).


Acute treatment of SE, and particularly SRSE and ventilation, are associated with high hospital costs and prolonged LOS. Extrapolation to the whole of Germany indicates that SE causes hospital costs of >€200 million per year. Along with the demographic change, incidence of SE will increase and costs for hospital treatment and sequelae of SE will rise.

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People with Epilepsy Want to Know About the Risk of SUDEP, Study Suggests

Epilepsy Research - Mon, 10/17/2016 - 07:25

People with epilepsy want neurologists to inform them about the risk of sudden unexpected death in epilepsy (SUDEP), according to a study published in the scientific journal Epilepsy and Behavior. Those who took part in the study also believed that the optimal timing and setting to provide SUDEP counselling should be determined on a case-by-case basis.

Dr Rajesh Ramachandran Nair and Dr Susan M Jack, at McMaster University, in Ontario, invited 42 people to take part in the study. Their aim was to better understand the views of adults with epilepsy on a) whether the issue of SUDEP should be discussed, and b) when and how this discussion should take place.

A total of 23 people, aged between 18 and 65 years, agreed to participate in the study. Nineteen were interviewed by telephone and four joined a focus group to share their views.

All participants felt that people diagnosed with epilepsy should be informed about SUDEP, and many believed that the best time to receive this information was at diagnosis.

Most subjects thought that the discussion about SUDEP should take place face to face, with a neurologist, and that people should then be given written information (including possible ways of preventing SUDEP) to take home.

Many participants believed that information about SUDEP should be incorporated into the general information given about epilepsy, rather than being provided separately.

SUDEP is the leading cause of disease-related death in people with epilepsy, with an incidence of between 0.9 and 9 per 1000 people per year.

Although published guidelines and position statements from professional organisations recommend routine counselling about SUDEP, research has shown that only a small proportion of neurologists offer this to their patients, because they fear causing anxiety and stress.

Author: Dr Özge Özkaya

 SUDEP Awareness Day is on 23 October 2016, and there are lots of ways in which you can get involved!

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Diazepam is as Effective as Lorazepam in Treating Status Epilepticus

Epilepsy Research - Mon, 10/17/2016 - 06:08

A recent study, published in the scientific journal Epilepsy and Behavior, shows that lorazepam injection is not more effective than diazepam injection in controlling seizures.

According to guidelines and expert consensus, lorazepam should be used preferentially over diazepam as the initial treatment of convulsive status epilepticus. However, this new study suggests that there is not enough evidence to support this practice.

The researchers, led by Dr Eugen Trinka, at Paracelsus Medical University, in Salzburg, systematically searched several databases for randomised controlled clinical trials comparing the effects of lorazepam and diazepam injections in the treatment of convulsive status epilepticus.

They identified five randomised clinical trials, involving a total of 656 subjects (320 of whom had been allocated to lorazepam injection and 336 of whom had been allocated to diazepam injection).

The researchers assessed the efficacy of both drugs by looking at measures such as: the cessation of clinical seizures and whether seizures stopped after a single dose of medication; whether status epilepticus continued and required a different antiepileptic drug; the need for ventilator support; and the presence of clinically relevant low blood pressure.

The results showed no significant difference, for any of these measures, between the people treated with lorazepam and those treated with diazepam injection. The scientists conclude from this that there is no evidence supporting the preferential use of lorazepam injection over diazepam injection as a first-line treatment of convulsive status epilepticus. They do note, however, that a difference in efficacy between the two drugs that requires a larger number of participants to detect may still exist.

The authors state that, in the future, researchers should use consistent definitions of status epilepticus and report results using clear and standardised methods. They add: “Individual patient data should also be provided to allow more detailed and informative analyses.”

Author: Dr Özge Özkaya

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Addressing Executive Dysfunction Could Improve Quality of Life For Children with Drug-Resistant Epilepsy

Epilepsy Research - Fri, 10/14/2016 - 10:26

The authors of a recent study recommend that executive functioning (the set of skills that allows people to plan, organise and complete tasks) be assessed and ‘targeted’ in children with drug-resistant epilepsy. They also call for further research to find out what the best targeting methods might be.

Executive functioning in children is tightly linked to cognition (the ability to think), and poor control of executive functioning may lead to weaknesses in areas that depend on skills such as memory and reading, for example academic achievement. It is known that children with epilepsy are vulnerable to executive dysfunction; however this is the first study to properly explore the relationship between executive functioning and quality of life.

During the investigation, researchers from Australia and the US carried out tests to measure the intellectual quotient (IQ) of 54 children with drug-resistant epilepsy, who were candidates for surgery. Parents were asked to complete ‘Quality of Life in Childhood Epilepsy’ (QOLCE) and ‘Behavior Rating Inventory of Executive Function’ (BRIEF) questionnaires, rating their child’s quality of life and executive function.

When analysing the results, the scientists needed to take into consideration factors that might have their own influence on quality of life or even executive ability (e.g. IQ, seizure frequency, an earlier age of epilepsy onset, taking  more epilepsy drugs). They report that, based on their data, clinically impaired executive function was linked to almost a 10 fold increased risk of a poor quality of life.

The authors conclude that the identification of executive dysfunction at home is an essential part of pre-surgical evaluation, and that targeting this area for intervention may improve the quality of life of these children.

Author: Dr Özge Özkaya

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Identification of risk for severe psychiatric comorbidity in pediatric epilepsy

Epilepsia - Fri, 10/14/2016 - 07:55
Summary Objective

This study identified items on the Child Behavior Checklist (CBCL) that predict those children and adolescents with epilepsy at highest risk for multiple psychiatric diagnoses.


Three hundred twenty-eight children, ages 5–18 years, and their parents participated in separate structured psychiatric interviews about the children, which yielded Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR) diagnoses. Parents completed the CBCL. The sample was divided into a younger (≤12 years, n = 214) group and an older (>12–18 years, n = 114) group. This study identified a reduced set of parent-reported CBCL items associated with Multiple Diagnoses versus Single Diagnosis versus No Diagnosis using chi-square tests and stepwise logistic regression. We then performed a generalized logistic regression with Multiple Diagnoses versus Single Diagnosis versus No Diagnosis as the dependent variable and the reduced CBCL set of items as predictors. We calculated the area under the ROC (receiver operating characteristic) curve (AUC) as a measure of diagnostic accuracy for pairwise comparisons.


For the younger group, seven items (clingy, cruelty/bullying, perfectionist, nervous, poor school work, inattentive, and sulks) had high diagnostic accuracy (AUC = 0.88), and for the older group, three items (disobedient at school, loner, and lies/cheats) had high accuracy (AUC = 0.91) when comparing children with multiple psychiatric diagnoses to children with no diagnosis. For both age groups, there was less diagnostic accuracy in identifying children with a single versus no diagnosis (AUC = 0.75 [young]; 0.70 [older]).


These findings suggest that responses to these two subsets of parent-reported CBCL items should alert clinicians to children and adolescents with epilepsy at risk for multiple psychiatric diagnoses and in need of a psychiatric referral.

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Incidence and risk factors of posttraumatic seizures following traumatic brain injury: A Traumatic Brain Injury Model Systems Study

Epilepsia - Fri, 10/14/2016 - 07:45
Summary Objective

Determine incidence of posttraumatic seizure (PTS) following traumatic brain injury (TBI) among individuals with moderate-to-severe TBI requiring rehabilitation and surviving at least 5 years.


Using the prospective TBI Model Systems National Database, we calculated PTS incidence during acute hospitalization, and at years 1, 2, and 5 postinjury in a continuously followed cohort enrolled from 1989 to 2000 (n = 795). Incidence rates were stratified by risk factors, and adjusted relative risk (RR) was calculated. Late PTS associations with immediate (<24 h), early (24 h–7 day), or late seizures (>7 day) versus no seizure prior to discharge from acute hospitalization was also examined.


PTS incidence during acute hospitalization was highest immediately (<24 h) post-TBI (8.9%). New onset PTS incidence was greatest between discharge from inpatient rehabilitation and year 1 (9.2%). Late PTS cumulative incidence from injury to year 1 was 11.9%, and reached 20.5% by year 5. Immediate/early PTS RR (2.04) was increased for those undergoing surgical evacuation procedures. Late PTS RR was significantly greater for individuals who self-identified as a race other than black/white (year 1 RR = 2.22), and for black individuals (year 5 RR = 3.02) versus white individuals. Late PTS was greater for individuals with subarachnoid hemorrhage (year 1 RR = 2.06) and individuals age 23–32 (year 5 RR = 2.43) and 33–44 (year 5 RR = 3.02). Late PTS RR years 1 and 5 was significantly higher for those undergoing surgical evacuation procedures (RR: 3.05 and 2.72, respectively).


In this prospective, longitudinal, observational study, PTS incidence was similar to that in studies published previously. Individuals with immediate/late seizures during acute hospitalization have increased late PTS risk. Race, intracranial pathologies, and neurosurgical procedures also influenced PTS RR. Further studies are needed to examine the impact of seizure prophylaxis in high-risk subgroups and to delineate contributors to race/age associations on long-term seizure outcomes.

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