Costs and cost-driving factors for acute treatment of adults with status epilepticus: A multicenter cohort study from Germany
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).Methods
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.Results
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%).Significance
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.
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!
Click here to read more stories about living with epilepsy.
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
Click here for more articles about conditions related to epilepsy.
Addressing Executive Dysfunction Could Improve Quality of Life For Children with Drug-Resistant Epilepsy
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
Click here for more news articles about epilepsy in children.
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.Methods
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.Results
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]).Significance
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.
Incidence and risk factors of posttraumatic seizures following traumatic brain injury: A Traumatic Brain Injury Model Systems Study
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.Methods
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.Results
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).Significance
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.
Acute treatment with minocycline, but not valproic acid, improves long-term behavioral outcomes in the Theiler's virus model of temporal lobe epilepsy
Infection with Theiler's murine encephalomyelitis virus (TMEV) in C57Bl/6J mice induces acute seizures and development of spontaneous recurrent seizures and behavioral comorbidities weeks later. The present studies sought to determine whether acute therapeutic intervention with an anti-inflammatory–based approach could prevent or modify development of TMEV-induced long-term behavioral comorbidities. Valproic acid (VPA), in addition to its prototypical anticonvulsant properties, inhibits histone deacetylase (HDAC) activity, which may alter expression of the inflammasome. Minocycline (MIN) has previously demonstrated an antiseizure effect in the TMEV model via direct anti-inflammatory mechanisms, but the long-term effect of MIN treatment on the development of chronic behavioral comorbidities is unknown.Methods
Mice infected with TMEV were acutely administered MIN (50 mg/kg, b.i.d. and q.d.) or VPA (100 mg/kg, q.d.) during the 7-day viral infection period. Animals were evaluated for acute seizure severity and subsequent development of chronic behavioral comorbidities and seizure threshold.Results
Administration of VPA reduced the proportion of mice with seizures, delayed onset of symptomatic seizures, and reduced seizure burden during the acute infection. This was in contrast to the effects of administration of once-daily MIN, which did not affect the proportion of mice with seizures or delay onset of acute symptomatic seizures. However, VPA-treated mice were no different from vehicle (VEH)–treated mice in long-term behavioral outcomes, including open field activity and seizure threshold. Once-daily MIN treatment, despite no effect on the maximum observed Racine stage seizure severity, was associated with improved long-term behavioral outcomes and normalized seizure threshold.Significance
Acute seizure control alone is insufficient to modify chronic disease comorbidities in the TMEV model. This work further supports the role of an inflammatory response in the development of chronic behavioral comorbidities and further highlights the utility of this platform for the development of mechanistically novel pharmacotherapies for epilepsy.
A new study published in the journal, Epilepsia, suggests that short-term improvements in memory following childhood epilepsy surgery might not be sustained in the long term.
These findings may be helpful for physicians, people with epilepsy and their families to better understand the possible outcomes of epilepsy surgery in childhood, and the effects of continuing antiepileptic drug (AED) treatment.
For the study, Klajdi Puka and Dr Mary Lou Smith, at the University of Toronto, analysed the verbal and visual memory skills of 88 people (average age 20.05 years) who had been diagnosed with drug-resistant epilepsy in childhood, and who had undergone evaluation for surgical treatment. Fifty-three of the subjects had actually undergone epilepsy surgery – between 4 and 11 years earlier – and the remaining 35 served as non-surgical controls. The researchers used standardised recall tests (involving stories, faces, word pairs and word lists) to assess the participants’ memory abilities, and they compared the results to those the subjects had achieved during surgical evaluation. Please note: the older tests were performed at what is referred to as the baseline time point, whilst the new ones were long-term follow-up assessments.
When the team analysed the results, they found no improvement in the subjects’ memory abilities over time (i.e. between baseline and follow-up). They also discovered that the participants’ memory outcomes were largely independent of whether or not they had undergone surgery.
People who were seizure-free at follow-up were shown to have better story recall at both time points than those who weren’t, but no improvement in their scores was found between the time points.
For subjects with epilepsy outside of the temporal lobe (extra-temporal lobe epilepsy), word list recall significantly declined over time regardless of whether or they had undergone surgery, or what their seizure status was.
The side of the seizure focus (the region in which seizures originate) only appeared to make a difference in people with temporal lobe epilepsy – those with left temporal lobe epilepsy (TLE) achieving lower story recall scores at follow-up than those with right TLE.
The researchers also observed that participants who underwent surgery tended to achieve seizure freedom sooner (if they did at all), and use fewer AEDs at follow-up, than those who did not.
The authors conclude from this that memory outcomes in the long term are independent of surgical status, and that there appears to be no improvement in memory performance over time, even in people who are seizure-free at follow-up. They also note, however, that surgery may be linked to more prompt seizure freedom and the need for fewer AEDs at follow-up.
Children with epilepsy can experience difficulties with many types of memory, including episodic memory (memory of events), semantic memory (memory of abstract concepts) and autobiographical memory. They are also prone to abnormally rapid forgetting. This is the first study to examine the long-term effect of surgery on memory.
Author: Dr Özge Özkaya
Click here for more articles about other treatments for epilepsy.
Restriction spectrum imaging reveals decreased neurite density in patients with temporal lobe epilepsy
Diffusion tensor imaging (DTI) has become a popular tool for delineating the location and extent of white matter injury in temporal lobe epilepsy (TLE). However, DTI yields nonspecific measures that are confounded by changes occurring within both the intracellular and extracellular environments. This study investigated whether an advanced diffusion method, restriction spectrum imaging (RSI) could provide a more robust measure of white matter injury in TLE relative to DTI due to RSI's ability to separate intraaxonal diffusion (i.e., neurite density; ND) from diffusion associated with extraaxonal factors (e.g., inflammation; crossing fibers).Methods
RSI and DTI scans were obtained on 21 patients with TLE and 11 age-matched controls. RSI-derived maps of ND, isotropic-hindered (IH) and isotropic-free (IF) water, and crossing fibers (CFs) were compared to DTI-derived fractional anisotropy (FA) maps. Voxelwise and tract-based analyses were performed comparing patients with TLE to controls on each diffusion metric.Results
Reductions in FA were seen primarily in frontotemporal white matter in TLE, and they were most pronounced proximal to the seizure focus. Reductions in ND corresponded to those seen in the FA maps; however, ND reductions were greater in magnitude, more lateralized to the epileptogenic hemisphere, and showed a broader pattern. Increases in IF/IH and effects from CFs also contributed to reduced FA in the ipsilateral parahippocampal cingulum and fornix, with decreases in IH extending into extratemporal regions. Reduced ND of the uncinate fasciculus was associated with longer disease duration, whereas FA was not associated with any clinical variables.Significance
RSI may provide a more specific measure of white matter pathology in TLE, distinguishing regions primarily affected by axonal/myelin loss from those where CFs and increases in extracellular water also play a role. By providing a more specific measure of axonal/myelin loss, RSI-derived ND may better reflect overall white matter burden in epilepsy.
To investigate whether prepregnancy overweight in women with epilepsy increases their risk for complications during pregnancy and delivery.Methods
This study is based on The Norwegian Mother and Child Cohort Study (MoBa) linked to the Medical Birth Registry of Norway. A diagnosis of epilepsy was reported in 706 pregnancies. Overweight was defined as body mass index ≥ 25 prepregnancy. Overweight women with epilepsy (n = 259) were compared to normal-weight women with epilepsy (n = 416), and to women without epilepsy with and without overweight (n = 30,516 and n = 67,977, respectively). The risks of pregnancy and delivery complications were calculated as odds ratios (ORs) with 95% confidence intervals (CIs) adjusted for adverse socioeconomic factors, age, parity, and smoking.Results
Women with epilepsy were more often overweight than women without epilepsy (38.4% vs. 31.3%, p < 0.001). The majority of pregnancy and delivery complications were more frequent in overweight women with epilepsy. Compared to overweight women without epilepsy, the risk was increased for cesarean section (OR 1.6, CI 1.2–2.2, p < 0.001), excessive bleeding (OR 1.4, CI 1.0–1.8, p = 0.04), peripartum anxiety and depressive symptoms (OR 1.9, CI 1.3–2.8, p < 0.001), small for gestational age children (OR 2.4, CI 1.2–4.8, p = 0.02), and transfer of the infant to a neonatal ward (OR 1.5, CI 1.1–2.2, p = 0.02). Compared to normal-weight women with epilepsy, the risk of cesarean section (OR 1.6, CI 1.1–2.3, p < 0.05), gestational hypertension (OR 2.0, CI 1.1–3.5, p < 0.05), preeclampsia (OR 2.3, CI 1.2–4.5, p < 0.05), and transfer of the infant to a neonatal ward (OR 2.2, CI 1.3–3.6, p < 0.01) was increased.Significance
Prepregnancy overweight in combination with epilepsy entails a strong negative effect on risk of complications during pregnancy and delivery. In women with epilepsy and overweight referral to a nutritionist should be considered when an antiepileptic drug is started as well as when pregnancy is planned. These women should be regarded as a high-risk group.
2-Deoxy-d-glucose enhances tonic inhibition through the neurosteroid-mediated activation of extrasynaptic GABAA receptors
The inhibition of glycolysis exerts potent antiseizure effects, as demonstrated by the efficacy of ketogenic and low-glucose/nonketogenic diets in the treatment of drug-resistant epilepsy. ATP-sensitive potassium (KATP) channels have been initially identified as the main determinant of the reduction of neuronal hyperexcitability. However, a plethora of other mechanisms have been proposed. Herein, we report the ability of 2-deoxy-d-glucose (2-DG), a glucose analog that inhibits glycolytic enzymes, of potentiating γ-aminobutyric acid (GABA)ergic tonic inhibition via neurosteroid-mediated activation of extrasynaptic GABAA receptors.Methods
Acute effects of 2-DG on the ATP-sensitive potassium currents, GABAergic tonic inhibition, firing activity, and interictal events were assessed in hippocampal slices by whole-cell patch-clamp and local field potential recordings of dentate gyrus granule cells.Results
Acute application of 2-DG activates two distinct outward conductances: a KATP channel–mediated current and a bicuculline-sensitive tonic current. The effect of 2-DG on such GABAergic tonic currents was fully prevented by either finasteride or PK11195, which are specific inhibitors of the neurosteroidogenesis pathway acting via different mechanisms. Moreover, the oxidized form of vitamin C, dehydroascorbic acid, known for its ability to induce neurosteroidogenesis, also activated a bicuculline-sensitive tonic current in a manner indistinguishable from that of 2-DG. Finally, we found that the enhancement of KATP current by 2-DG primarily regulates intrinsic firing rate of granule cells, whereas the increase of the GABAergic tonic current plays a key role in reducing the frequency of interictal events evoked by treatment of hippocampal slices with the convulsive agent 4-aminopyridine.Significance
We demonstrated, for the first time, that 2-DG potentiates the extrasynaptic tonic GABAergic current through activation of neurosteroidogenesis. Such tonic inhibition represents the main conductance responsible for the antiseizure action of this glycolytic inhibitor.
MicroRNA-139-5p negatively regulates NR2A-containing NMDA receptor in the rat pilocarpine model and patients with temporal lobe epilepsy
Regulation of N-methyl-d-aspartate (NMDA) subunits NR2A and NR2B expression during status epilepticus (SE) remains incompletely understood. Here we explored the role of brain-enriched microRNA (miR)-139-5p in this process.Methods
miRNA microarray was performed to examine changes in miRNA expression in the rat pilocarpine model following NMDA-receptor blockade. The dynamic expression patterns of miR-139-5p, NR2A, and NR2B levels were measured in rats during the three phases of temporal lobe epilepsy (TLE) development using quantitative reverse transcription polymerase chain reaction (qRT-PCR) and Western blot. Similar expression methods were applied to hippocampi obtained from patients with TLE and from normal controls. Moreover, miR-139-5p agomir and antagomir were utilized to explore the role of miR-139-5p in determining NMDA-receptor subunit expression patterns.Results
We identified 18 miRNAs that were significantly altered in the rat pilocarpine model following NMDA-receptor blockade. Of these, miR-139-5p was significantly up-regulated and Grin2A was predicted as its potential putative target. In patients with TLE, miR-139-5p expression was significantly down-regulated, whereas NR2A and NR2B levels were significantly up-regulated. In the rat model of SE, miR-139-5p expression was down-regulated while NR2A was up-regulated in the acute and chronic phases, but not in the latent phase. NR2B expression was up-regulated during the three phases of TLE development. Overexpression of miR-139-5p decreased, whereas depletion of miR-139-5p enhanced the expression levels of NR2A, but not NR2B, induced by pilocarpine treatment. Of interest, NMDA nonselective antagonist and NR2A selective antagonist enhanced miR-139-5p levels suppressed by pilocarpine treatment, whereas the NR2B selective antagonist was ineffective.Significance
These findings elucidate the potential role of miR-139-5p in NMDA-receptor involvement in TLE development and may provide novel therapeutic targets for the future treatment of TLE.
Little is known about the long-term cognitive outcomes following pediatric epilepsy surgery. Although the evidence for change within the first 2 years is not compelling, the plasticity of the immature brain may allow for improvements in the long term. This study examined memory function in a cohort of surgical and nonsurgical patients at baseline and 4–11 years after.Method
Participants were 88 patients (mean age 20.05, standard deviation [SD] 4.21 years) with childhood-onset intractable epilepsy; 53 had undergone resective epilepsy surgery. Verbal and visual memory were assessed at baseline and follow-up using standardized tests of recall of stories, faces, word pairs, and word lists.Results
Improvements over time were not found; outcomes were largely independent of surgical status. Those who were seizure-free at follow-up had better story recall at both times (p = 0.028), and did not show improvement. Among patients with extratemporal lobe epilepsy, significant declines in word list recall were found over time irrespective of surgical or seizure status (p = 0.010). Effects of laterality of seizure focus were evident only when examining patients with temporal lobe epilepsy (TLE); patients with left TLE had lower story recall scores compared to patients with right TLE at long-term follow-up (p = 0.043).Significance
Patients who became seizure-free had some advantages in memory, but did not show improvements over time. These findings have important implications for understanding potential outcomes from surgery or continued use of antiepileptic medications.
The findings of a study at Southern Illinois University suggest that alcohol withdrawal in people with epilepsy (i.e. the alcohol-free period that follows a prolonged period of regular/heavy drinking) increases the risk of death following a seizure. This could be caused by respiratory compromise and longer seizure duration, which are both recognised risk factors for sudden unexpected death in epilepsy (SUDEP). Efforts to prevent excessive drinking in people with epilepsy should, therefore, form part of the strategy to reduce SUDEP risk.
According to the authors of the study, which is published in the scientific journal Epilepsy and Behavior, people with epilepsy who drink heavily/excessively should be carefully monitored during withdrawal periods, when they are particularly susceptible to seizures.
For the investigation, researchers led by Dr Carl Faingold evaluated the effects of ethanol (alcohol) withdrawal in a genetic rodent model of epilepsy. They subjected the rodents a four-day ‘binge’ ethanol treatment, and then induced epileptic seizures in them 18-24 hours after the last ethanol dose (i.e. during alcohol withdrawal). The team then assessed the animals’ breathing patterns, how long they were confused for after a seizure and how many of them suffered seizure-induced death.
They compared the findings with those from two other animal groups, which they also included in the study. One contained the same epilepsy models that were in the original group, but these received a non-alcoholic treatment instead of ethanol, and the other contained healthy (non-epileptic) rodents who received ethanol treatment. Aside from these differences, all procedures and assessments undergone by the animals were the same.
The scientists found that, following seizures, all of the epilepsy models showed a loss of the ‘righting reflex’ (which allows the body to gain an upright position following a fall) and respiratory distress. These signs were not seen in the healthy animals.
They also observed that epilepsy models subjected to ethanol withdrawal showed a significant increase in both the duration of confusion following a seizure, and respiratory distress, compared to those that did not receive ethanol.
Finally, the researchers found that significantly more of the epilepsy models subjected to ethanol withdrawal experienced seizure-induced death than either the epilepsy models not treated with ethanol or the healthy animals.
They conclude that ethanol withdrawal causes a significant increases in the duration of confusion following a seizure as well, as respiratory distress, which contributes to the greater incidence of mortality in rodents that are genetically prone to epilepsy.
In this experiment, the team in Illinois aimed to create a state of alcohol withdrawal that was as close as possible to the human condition. Their results suggest that alcohol consumption is something that should be specifically discussed by people with epilepsy and their doctors.
Author: Dr Özge Özkaya
Click here to read more stories about living with epilepsy.
Depression may worsen cognitive abilities (thinking skills) in people with temporal lobe epilepsy (TLE), according to a study published in the Journal of Neuropsychiatry and Clinical Neuroscience. Treating depression in this group of people could therefore lead to improvements in cognition.
The study, led by Dr Jennifer Davis, at Brown University in Rhodes Island, analysed how depression contributes to reduced executive functioning in people with TLE.
Executive functioning is defined as a set of cognitive processes that are necessary for the cognitive control of behaviour. In other words, it is a set of skills that allows people to plan, organise and complete tasks. There are eight key executive functions that are used to organise and act on information, which include impulse control, emotional control, flexible thinking, working memory, self monitoring, planning and prioritising, task initiation and organisation. A significant proportion of people with TLE experience impairment in executive functioning.
The researchers recruited a total of 82 people, of whom 29 had TLE only, 22 had TLE and depression and 31 had depression only. They asked the participants to complete the Delis-Kaplan Executive Function System, a neuropsychological test that measures a variety of verbal and nonverbal executive functions and provides an evaluation of higher-level cognitive functions.
The results showed that subjects with both TLE and depression had poorer executive functioning than those with TLE only.
According to the authors: “These findings support the notion that depression may further contribute to executive difficulties in individuals with TLE.” They suggest that the types of deficits associated with depression in TLE may be different than those associated with other types of depression. They conclude that future studies should investigate which aspects of executive functioning improve when depression is treated in TLE.
Author: Dr Özge Özkaya
Click here for more articles about conditions related to epilepsy.
Ripples on spikes show increased phase-amplitude coupling in mesial temporal lobe epilepsy seizure-onset zones
Ripples (80–150 Hz) recorded from clinical macroelectrodes have been shown to be an accurate biomarker of epileptogenic brain tissue. We investigated coupling between epileptiform spike phase and ripple amplitude to better understand the mechanisms that generate this type of pathologic ripple (pRipple) event.Methods
We quantified phase amplitude coupling (PAC) between epileptiform electroencephalography (EEG) spike phase and ripple amplitude recorded from intracranial depth macroelectrodes during episodes of sleep in 12 patients with mesial temporal lobe epilepsy. PAC was determined by (1) a phasor transform that corresponds to the strength and rate of ripples coupled with spikes, and a (2) ripple-triggered average to measure the strength, morphology, and spectral frequency of the modulating and modulated signals. Coupling strength was evaluated in relation to recording sites within and outside the seizure-onset zone (SOZ).Results
Both the phasor transform and ripple-triggered averaging methods showed that ripple amplitude was often robustly coupled with epileptiform EEG spike phase. Coupling was found more regularly inside than outside the SOZ, and coupling strength correlated with the likelihood a macroelectrode's location was within the SOZ (p < 0.01). The ratio of the rate of ripples coupled with EEG spikes inside the SOZ to rates of coupled ripples in non-SOZ was greater than the ratio of rates of ripples on spikes detected irrespective of coupling (p < 0.05). Coupling strength correlated with an increase in mean normalized ripple amplitude (p < 0.01), and a decrease in mean ripple spectral frequency (p < 0.05).Significance
Generation of low-frequency (80–150 Hz) pRipples in the SOZ involves coupling between epileptiform spike phase and ripple amplitude. The changes in excitability reflected as epileptiform spikes may also cause clusters of pathologically interconnected bursting neurons to grow and synchronize into aberrantly large neuronal assemblies.
Quality and safety in epilepsy monitoring units (EMUs) are of great importance because patients’ seizures are induced rather than prevented in this hospital setting. However, the measurement and evaluation of quality and safety in EMUs are heterogeneous, as are practices and processes of care. To improve the measurement of quality and safety in EMUs, we sought to develop evidence-based and consensus-driven quality indicators, adhering to previously described methodologic standards.Methods
Candidate quality indicators were identified using a recent systematic review on quality and safety indicators in EMUs. These were supplemented by expert opinion to identify other indicators that had not been reported previously. The candidate quality indicators were then evaluated using a modified Delphi technique among a multidisciplinary EMU quality improvement team. Candidate indicators identified as important and feasible through the Delphi technique were then developed into quality metrics.Results
Thirty-four candidate indicators were abstracted from 135 studies included in the earlier systematic review, and two additional candidate indicators were suggested through consensus from experts. Consensus was reached after two modified Delphi rounds for 25 quality indicators identified as important. These 25 indicators were then developed into quality metrics using a standardized data collection form and were deployed in an online database for systematic data capture and further analyses.Significance
These quality indicators have the potential to improve the reporting of quality and safety in EMUs through standardized measurement and evaluation of the quality and safety of care. The ultimate goal is improved patient care and clinical outcomes through safer and better care for people with epilepsy in the EMU.
Surgery for refractory (drug-resistant) epilepsy may improve psychological changes and psychiatric problems seen in some people with epilepsy, according to a study published in the scientific journal, Epilepsia.
First Author Dr Sònia Ramos-Perdigués, at Can Misses Hospital, in Spain, said: “The results of this study suggest that surgery for refractory epilepsy may provide additional benefit in patients with a psychiatric history and should be considered in this population.”
In order to assess the relationship between epilepsy surgery and psychiatric disorders, the researchers analysed the psychiatric outcome in people with drug-resistant epilepsy who underwent surgery.
They first evaluated the psychiatric condition of 85 participants before surgery using tools such as the ‘Wechsler Adult Intelligence Scale’ and ‘Hospital Anxiety and Depression Scale’, and then repeated the assessments six month after surgery. They compared the results to those obtained from 68 subjects with drug-resistant epilepsy who were not eligible for surgery,
The results showed that the perception of distress significantly improved in participants who underwent surgery compared to those who did not. Several other measures of psychological changes such as somatisation, where psychological distress in unconsciously expressed as physical symptoms, and paranoia also improved. Finally, symptoms of depression and anxiety decreased following surgery.
“Epilepsy patients with a history of psychiatric disorders may be concerned about the potential effect of surgery on their mental condition. As a result, some patients and physicians might have been reluctant to utilize surgery for refractory epilepsy, for fear of worsening emotional suffering,” said Dr Ramos-Perdigués.
This study suggests that the contrary may be the case and provides evidence that surgery could improve psychiatric functioning in drug-resistant epilepsy.
Author: Dr Özge Özkaya
Click here for more articles about other treatments for epilepsy.