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About Our Partner: Elsevier PublishingElsevier is an integral partner with the scientific, technical and health communities, delivering superior information products and services that foster communication, build insights, and enable individual and collective advancement in scientific research and health care. Elsevier. Building Insights. Breaking Boundaries. Epilepsy & Behavior, a professional medical journal from Elsevier Publishing, presents original peer-reviewed reports and reviews that pertain to the behavioral aspects of epilepsy. The articles are based on laboratory and clinical research. The Epilepsy Foundation and Epilepsy& Behaviorhave joined in partnership to provide select content from the journal. Articles posted on February 5, 2010 Cognition across the lifespan: Antiepileptic drugs, epilepsy, or both? Cognitive problems in persons with epilepsy manifest over a lifetime; however, whether abnormal cognition in an individual with epilepsy is a result of comorbid brain substrate, the epilepsy itself or its underlying etiology, the antiepileptic agents used to control it, or a combination of these and other factors remains controversial. There is a continuing need for improved therapies to control seizures and reduce the incidence of adverse events, especially those involving the central nervous system that compromise attention, intelligence, language skills, verbal and nonverbal memory, executive function, and psychomotor speeds. Although cognitive decline typically occurs among patients with more severe epilepsy, physicians must judiciously select therapy with an eye toward not only controlling seizures but also ensuring that all patients retain as much function as possible throughout their lives. Copyright 2009 Elsevier Inc. All rights reserved. Psychosocial factors associated with stigma in adults with epilepsy Living Well with Epilepsy II called for further attention to stigma and its impact on people with epilepsy. In response, the South Carolina Health Outcomes Project on Epilepsy (SC HOPE) is examining the relationship between socioeconomic status, epilepsy severity, health care utilization, and quality of life in persons diagnosed with epilepsy. The current analysis quantifies perceived stigma reported by adults with epilepsy in relation to demographic, seizure-related, health, and psychosocial factors. It was found that reported levels of stigma were associated with interactions of seizure worry and employment status, self-efficacy and social support, and quality care and age at seizure onset. This information may be used to target and develop evidence-based interventions for adults with epilepsy at high risk for perceived stigma, as well as to inform epilepsy research in self-management. Copyright 2009 Elsevier Inc. All rights reserved. Articles Posted on December 7, 2009 The experience of seizures after epilepsy surgery Postoperative seizures occur in 20–60% of patients who have epilepsy surgery. Despite this, there is limited understanding of a patient’s experience of the recurrence of seizures after surgery. This study used a qualitative approach to identify key themes derived from content analysis of 15 in-depth patient interviews about the experience of seizure recurrence. The results showed a prominence of psychological issues over medical concerns. The four most frequently expressed themes were perceived success of surgery, medication, acceptance of seizure recurrence, and personal independence. Despite seizure recurrence, patient sentiments were not universally negative; rather there was heterogeneity of views, with some reporting ambivalence and others a sense of satisfaction with outcome. The findings provide evidence for the importance of cognitive reframing and benefit finding in the context of seizure recurrence.Copyright 2009 Elsevier Inc. All rights reserved. An in-office linguistic study was conducted to assess neurologist–patient discussions of epilepsy. Naturally occurring interactions among 20 neurologists and 60 of their patients with epilepsy were recorded. Participants were interviewed separately postvisit. Transcripts were analyzed using sociolinguistic techniques. Of 59 patients taking antiepileptic drugs previsit, 44 (75%) discussed side effects with their neurologist. Side effect discussions were most often neurologist initiated. Postvisit, patients and neurologists often disagreed about which side effects were experienced. The presence of a caregiver (e.g., spouse) usually resulted in lengthier, more detailed discussions of side effects, without drastically increasing overall visit length. Discussions of mood- and behavior-related comorbidities occurred infrequently (14 of 60 visits); postvisit, neurologists stated that they felt that management of these conditions was outside their area of expertise. Communication gaps observed in discussions of epilepsy and its treatment warrant further exploration. Additional research is currently underway to assess the efficacy of a previsit assessment tool. Copyright 2009 Elsevier Inc. All rights reserved. The 2008 Judith Hoyer Lecture: Epilepsy in children: Listening to mothers The incidence of epilepsy is significantly higher in children than adults. When faced with the diagnosis of epilepsy, parents have many questions regarding cause, treatment, and prognosis. Although the majority of children with epilepsy have an excellent prognosis and respond well to therapy, some children are refractory to therapy and suffer from cognitive decline. Animal models are now providing insights into the mechanisms responsible for the high incidence of seizures during development and age-dependent seizure-induced damage. One of the causes of the increased susceptibility of the young brain to seizures is the depolarizing effects of GABA secondary to high intracellular concentrations of chloride in young neurons. Although cell loss is not a feature of seizures in the young brain, recurrent seizures do result in aberrant sprouting of mossy fibers, reduce neurogenesis, and alter excitatory and inhibitory neurotransmitter receptor structure and function. Behavioral consequences of early-life seizures include impaired spatial cognition, which now can be assessed using single-cell recordings from the hippocampus. Antiepileptic drugs have had a tremendous positive influence in epilepsy management, although there are now a number of studies demonstrating that antiepileptic drugs at therapeutic concentrations can impair cognition and result in increased apoptosis. While clinical judgment and experience are paramount when discussing the consequences of seizures and their treatment, awareness of studies from animals can provide the clinician with guidance in addressing these important issues with parents. Copyright 2009 Elsevier Inc. All rights reserved. Objective: Subclinical seizures (SCSs) are characterized by paroxysmal rhythmic epileptiform discharges that evolve in time and space in the absence of objective clinical manifestation or report of a seizure. The aim of this study was to evaluate the frequency and characteristics of SCSs in children with localizationrelated epilepsy (LRE). Methods: The results of video/EEG monitoring were reviewed to identify patients with SCS. We identified 187 children diagnosed with LRE, in 32 of whom SCSs were reported in the EEG recording. Results: SCSs were reported only in the children who had received a diagnosis of either symptomatic or cryptogenic LRE. All children had a history of clinical seizure(s). The ictal onset of SCSs was most frequent from the temporal and frontal lobes. SCSs were lateralized to the left hemispheres in 19, right hemisphere in 8, and both hemispheres independently in 5 children. SCSs were more often reported in young children, and associated with a history of developmental delay, infantile spasms, and frequent seizures. EEG abnormalities included background slowing and lack of normal sleep architecture in addition to the epileptiform activity. Seizure freedom was reported less often in children with SCSs. Six patients seizure free at the time of the admission were found to have SCSs. Conclusion: Subclinical seizures are not uncommon in children with LRE, in particular, with younger age, developmental disability, and medically refractory clinical course. Video/EEG monitoring will be informative in selected children with LRE to assess the seizure frequency more accurately. Copyright 2009 Elsevier Inc. All rights reserved. Articles Posted on August 20, 2009 Consensus statement: The evaluation and treatment of people with epilepsy and affective disorders Affective disorders in people with epilepsy (PWE) have become increasingly recognized as a primary factor in the morbidity and mortality of epilepsy. To improve the recognition and treatment of affective disorders in PWE, an expert panel comprising members from the Epilepsy Foundation’s Mood Disorders Initiative have composed a Consensus Statement. This document focuses on depressive disorders in particular and reviews the appearance and treatment of the disorder in children, adolescents, and adults. Idiosyncratic aspects of the appearance of depression in this population, along with physiological and cognitive issues and barriers to treatment, are reviewed. Finally, a suggested approach to the diagnosis of affective disorders in PWE is presented in detail. This includes the use of psychometric tools for diagnosis and a stepwise algorithmic approach to treatment. Recommendations are based on the general depression literature as well as epilepsy-specific studies. It is hoped that this document will improve the overall detection and subsequent treatment of affective illnesses in PWE. Copyright Elsevier Inc. All rights reserved. Vagus nerve stimulation and magnet use: Optimizing benefits More than 10 years ago, the vagus nerve stimulator became the first device approved by the Food and Drug Administration for use in persons with epilepsy. The vagus nerve stimulator has subsequently served to spearhead the concept of neurostimulation for seizures. Chronic intermittent electrical stimulation of the left vagus nerve is the foundation for vagus nerve stimulation, yet little is known about its capability to deliver acute, on-demand, activation of stimulation through use of a magnet. Thus far, clinical use of magnet-induced vagus nerve stimulation has not been elucidated. In an effort to help guide management, we highlight current and potential uses of acute abortive therapy with vagus nerve stimulation. We review the current evidence that is available for vagus nerve stimulator magnet use, discuss potential clinical applications that exist, offer a protocol for magnet application within the institutional setting, provide our approach to titrating the magnet parameters, and make recommendations for magnet use that support an evolving standard of care. Copyright Elsevier Inc. All rights reserved. The medical literature related to knowledge of, beliefs about, and attitudes toward epilepsy was reviewed from the perspective of patients, caregivers, and health care providers. The literature points to a desire for enhanced epilepsy education by patients and caregivers; however, these needs have not been met by primary or specialty care. Surveys of general practitioners (GPs) point to limitations in knowledge and negative attitudes. GPs view their role in epilepsy care as primarily educational and tend to acknowledge their limitations by referring difficult cases. Ongoing education for GPs is important, as is an improved partnership in defining roles for care and education. Health care professionals specialized in epilepsy care acknowledge their own set of barriers to optimal care. Epilepsy education programs have been able to improve knowledge; however, long-term improvements in behavioral outcomes or quality of life are less documented. Suggestions for improvements are provided. Copyright Elsevier Inc. All rights reserved. Articles Posted on August 5, 2009 Are children with epilepsy at greater risk for bullying than their peers? The primary goal of this study was to determine the prevalence of bullying in children with epilepsy compared with their healthy peers and peers with chronic disease. Children with epilepsy were compared with healthy children and a cohort of children with chronic kidney disease (CKD). The following self-report questionnaires were completed: Revised Olweus Bully/Victim, Piers–Harris Self-Concept Scale, Revised Child Manifest Anxiety Scale, Child Depression Index, and Social Skills Rating System. Children with epilepsy were more frequently victims of bullying (42%) than were healthy controls (21%) or children with CKD (18%) (P = 0.01). Epilepsy factors such as early age at seizure onset, seizure type, and refractory epilepsy were not found to be predictors of victim status. Surprisingly, poor social skills, increased problem behaviors, poor self-concept, depression, and anxiety did not correlate with bully victim status. The relatively high prevalence of bullying behaviors in these children is concerning and, from a clinical standpoint, requires greater research specifically addressing peer relationships and consideration of the implementation of anti-bullying measures and coping strategies for children with epilepsy. Epilepsy stigma and stigma by association in the workplace In the first experimental study of epilepsy-based discrimination in the workplace, we examined the influence of stigmatization on the workplace outcomes of hypothetical employees who were associated with epilepsy, but who did not have epilepsy themselves (stigma by association). Participants (40 women, 16 men), acting as employers, evaluated one of six randomly assigned employee work portfolios that were identical except that the employee was either male or female and had taken leave during the past year to care for a child with either epilepsy or asthma, or for whom no leave was mentioned. They then evaluated the employee and made recommendations concerning the employee’s workplace rewards (promotion, raise) and penalties (job termination). Work quality evaluation was similar across conditions. However, parents of a child with epilepsy received fewer workplace rewards and greater workplace penalties than did employees in the other conditions. Implications for mental health and antibias interventions are discussed. Copyright 2009 Elsevier Inc. All rights reserved. Articles Posted on July 31, 2009 Drug treatment of epilepsy: Options and limitations The modern antiepileptic drug (AED) era—spanning a period of more than 150 years from the first use of bromide in 1857 to 2008—has seen the introduction into clinical practice of a diverse group of effective and safe drugs. These AEDs have provided considerable benefits for those afflicted with epilepsy of all kinds. In as many as 60–70% of newly treated patients, current AEDs lead to satisfactory control of seizures and a favorable risk–benefit balance for the great majority of patients, albeit with considerable differences in response depending on the type of seizure and epilepsy syndrome and rare serious adverse events. Unfortunately, in 20–30% of patients, epilepsy cannot be controlled. Patients with drug-resistant epilepsy often have serious comorbidity, including injury, depression, anxiety, and increased mortality. The aim of antiepileptic treatment should be to control seizures as quickly as possible with no or minimal side effects and with no negative impact on the quality of life. Improved seizure control is likely to reduce the morbidity and increased mortality associated with uncontrolled epilepsy. In this short overview, the options and the limitations of treating patients with epilepsy are briefly summarized. Emotional distress is one of the most frequently reported seizure precipitants in epilepsy, but little is known about its causes and processes. Interestingly, it is now accepted that emotional distress, such as anxiety, may be accompanied by evolutionary adaptation, or abnormal attentional vigilance toward threatening stimuli. The goal of this research was to study the link between emotional seizure precipitants and pathological attention-related biases toward threat in temporal lobe epilepsy (TLE). To this aim, patients were asked to report the extent to which seizures were elicited or not by emotional precipitants, allowing distinction of two groups: ‘‘Emo-TLE” group and ‘‘Other-TLE” group. Attentional biases were investigated by comparing patients’ emotional Stroop and dot detection paradigms with those of healthy individuals (control group). We found that the Emo-TLE group was characterized by attentional bias toward threatening stimuli compared with neutral stimuli and compared with the other two groups. We thus hypothesize that attentional biases related to threat in patients with TLE may sustain emotional vulnerability and seizure occurrence. Epilepsy and sudden death: Personal reflections and call for global action To solve the mystery of sudden unexpected death in persons with epilepsy (SUDEP), a global focus is needed to identify persons at risk, develop treatment regimens, and prevent its occurrence. A world wide network of professionals must focus on basic scientific research programs and clinical and epidemiology studies. Team work among different multidisciplinary professionals in clinical settings and within and among laboratories should address the global issues of SUDEP. If the correct term ‘SUDEP’ is used on autopsy reports and if verbal autopsies postmortem are conducted when needed, the true incidence of SUDEP may be found to be much higher than previously thought and the market for new antiepileptics and other drugs to prevent SUDEP will be larger. Symposia should discuss new data and lessons learned from the last 20 to 30 years to be applied by scientists and clinicians worldwide to gain a better understanding of SUDEP. ‘Think out of the box’ when evaluating an established animal model with potential for modification(s) to study mechanism(s) of SUDEP. Multiple relevant animal models are needed to understand the pathophysiology of SUDEP, hypothesize about effective treatments, develop small pilot studies in persons with epilepsy, and conduct confirmatory large-scale clinical trials. The fields of pharmacology, clinical pharmacology, and cardiology have much to offer as we work to improve compliance, develop new antiepileptic drugs, and apply different categories of drugs to resolve the mystery of SUDEP. Ambulatory simultaneous EKG and EEG telemetry monitoring of patients at risk for sudden death will help identify cardiac vs. brain epileptogenic triggers for treatment to decrease risk of SUDEP. Respiratory function monitoring is also needed. Academic fellowships and competitions for medical students, postdoctoral fellows, residents and faculty will attract medical and graduate trainees to work on SUDEP. Grant funding is essential to move the SUDEP knowledge base forward. Leaders must solve the global mystery of SUDEP using a leadership philosophy foundation that provides innovative vision and approaches for SUDEP research and teaching programs. The interaction of teaching and research is essential: while a student is learning how to conduct research he must simultaneously learn to become a teacher. Medical and graduate leaders must provide vision and a fertile environment to teach students of today to become the self learners and leaders of tomorrow to find solutions for SUDEP. Articles Posted on July 16, 2009 Female issues in epilepsy: A critical review ABSTRACT: The focus on gender-related issues for women with epilepsy has heightened in recent years. The emphasis, however, has been on the childbearing years. Epilepsy and antiepileptic drug treatment affect sexual development, the menstrual cycle, and aspects of contraception, fertility, and reproduction. Female patients with epilepsy at a reproductive age face a unique set of reproductive issues, ranging from descriptions of disorders of reproduction in epilepsy and its causes, to contraception, pregnancy, sexuality, menopause, and osteoporosis. Conditions and diseases that specifically affect women are discussed. The role of hormones across the life cycle—endogenous and exogenous hormones and their effects on drug interactions, drug metabolism, and therapeutic outcomes—is described. Contraception and pregnancy issues for women with epilepsy have received the appropriate attention. ABSTRACT: Women with epilepsy (WWE)’s knowledge of the interaction between antiepileptic drugs (AEDs) and oral contraceptives (OCs) and the potential teratogenicity of AEDs has received limited study. We conducted a cross-sectional questionnaire study (English or Spanish) among young WWE (18–44 years) to assess demographic characteristics, current AED use, and knowledge of AED interactions with OCs and teratogenicity. We used the Food and Drug Administration’s classification system to categorize each AED’s teratogenic potential. Participants (n = 148) had a mean age of 32 years (SD 8); 32% spoke Spanish and described themselves as Hispanic. Among women prescribed a cytochrome p450-inducing AED, 65% were unaware of decreased OC efficacy. Forty percent of those prescribed Category D AEDs were unaware of potential teratogenic effects. WWE have limited knowledge of the potential interaction between AEDs and OCs and the teratogenic effects of AEDs. Educational efforts should highlight the reproductive health effects of AEDs in WWE. Articles Posted on July 8, 2009 On the prevalence of bipolar disorder in epilepsy Although mood disorders represent a frequent psychiatric comorbidity in epilepsy, data on bipolar disorder (BD) are still limited, and the role of possible specific confounding variables (seizures and antiepileptic drug therapy) has never been considered. Data for 143 adult outpatients with epilepsy assessed with the Mini International Neuropsychiatric Interview Plus Version 5.0.0 using the Epilepsy Addendum for Psychiatric Assessment, the Mood Disorder Questionnaire, and the Interictal Dysphoric Disorder Inventory revealed that 11.8% had the Diagnostic and Statistical Manual of Mental Disorders-based diagnosis of BD, only 1.4% of whom could be considered as having ‘‘pure” BD, because in all other cases BD symptoms were related to phenotype copies of BD such as interictal dysphoric disorder of epilepsy, postictal manic or hypomanic states, and preictal dysphoria. Copyright 2009 Elsevier Inc. All rights reserved. Curing epilepsy: Progress and future directions During the past decade, substantial progress has been made in delineating clinical features of the epilepsies and the basic mechanisms responsible for these disorders. Eleven human epilepsy genes have been identified and many more are now known from animal models. Candidate targets for cures are now based upon newly identified cellular and molecular mechanisms that underlie epileptogenesis. However, epilepsy is increasingly recognized as a group of heterogeneous syndromes characterized by other conditions that co-exist with seizures. Cognitive, emotional and behavioral co-morbidities are common and offer fruitful areas for study. These advances in understanding mechanisms are being matched by the rapid development of new diagnostic methods and therapeutic approaches. This article reviews these areas of progress and suggests specific goals that once accomplished promise to lead to cures for epilepsy. Copyright 2009 Elsevier Inc. All rights reserved. As children’s perceptions of their quality of life are unique, it is essential to elicit their concerns directly rather than from proxy informants. This study therefore aimed to investigate the impact of childhood epilepsy on quality of life directly from the child’s perspective. Focus group techniques and qualitative analysis were utilized. Twenty-two children between 7 years 4 months and 12 years 6 months of age (11 females, 11 males) were stratified by age (7–8, 9–10, 11–12 years) into five focus groups. Data were transcribed and analyzed using grounded theory techniques to generate themes and categories. Themes were presented using the children’s language. Two major themes were identified, ‘‘things to do with growing up” and ‘‘things to do with epilepsy,” with five and four subthemes, respectively. No significant age-related differences were found. A conceptual model illustrates these findings, and comparisons are made to previous research with adolescents using similar methodology. Copyright 2009 Elsevier Inc. All rights reserved. The differential diagnosis of epilepsy: A critical review The wrong diagnosis of epilepsy is common. At referral epilepsy centers, psychogenic non-epileptic attacks are by far the most common condition found to have been misdiagnosed as epilepsy, with an average delay of 7–10 years. There are many ‘‘red flags” that can raise the suspicion of psychogenic non-epileptic attacks. Syncope is the second most common condition misdiagnosed as epilepsy, and it is probably more common in outpatient populations. Other conditions more rarely misdiagnosed as epilepsy include hypoglycemia, panic attacks, paroxysmal movement disorders, paroxysmal sleep disorders, TIAs, migraines, and TGA. Conditions specific to children include nonepileptic staring spells, breath-holding spells, and shudder attacks. At all ages, the over-interpretation of EEGs plays an important part in the misdiagnosis of epilepsy. Copyright 2009 Elsevier Inc. All rights reserved. Non-adherence to epilepsy medications can interfere with treatment and may adversely affect clinical outcomes, although few studies have examined this relationship. This study assessed barriers and drivers to adherence, its impact on quality of life, and the importance of the patient–physician relationship to adherence. Two cross-sectional online surveys were conducted among 408 adult patients with epilepsy and 175 neurologists who treat epilepsy patients. Twenty-nine percent of patients self-reported being non-adherent to antiepileptic medications in the prior month. Non-adherence was found to be associated with reduced seizure control, lowered quality of life, decreased productivity, seizure-related job loss, and seizure-related motor vehicle accidents. Patient-oriented epilepsy treatment programs and clear communication strategies to promote self-management and patients’ understanding of epilepsy are essential to maximizing treatment and quality of life outcomes while also minimizing economic costs. Copyright 2009 Elsevier Inc. All rights reserved. Dealing with epilepsy: Parents speak up In this study, focus groups were used to examine parents’ attitudes toward mental health services, use of mental health and other services, as well as service-related and other challenges encountered by parents of children with epilepsy. Both quantitative and qualitative analytic approaches were used to analyze the transcripts of 36 parents grouped into six focus groups by socioeconomic status (SES) (high, low) and ethnicity (African-American, Caucasian, Hispanic). The quantitative analyses demonstrated that, irrespective of SES and ethnicity, the parents were highly aware of their children’s behavioral, emotional, and cognitive difficulties and the lack of knowledge about epilepsy among medical, educational, and mental health professionals. The higher-SES parents were significantly more concerned about inadequate educational services and the need for medical services, but less concerned about mental health and medical service use than the lower-SES parents. Insufficient knowledge about epilepsy and about services, parent emotional difficulties, and use of educational services differed significantly by ethnicity. The qualitative analyses highlighted the parents’ concerns regarding misconceptions about epilepsy and the stigma toward mental health care among the African-American and Hispanic parents. These findings suggest the need for accessible and better-quality mental health, educational, and medical services for children with epilepsy irrespective of SES and ethnicity. They also underscore the importance of educating parents, service providers, and the general public about epilepsy. Copyright 2009 Elsevier Inc. All rights reserved. A cross-sectional study was conducted surveying patients with epilepsy about the current and potential role community pharmacists play/could play in their care. Seventy-five patients (mean age = 38.9 years, 66% female) were enrolled, either from the outpatient epilepsy clinic or from the local Epilepsy Foundation database. Patients were asked a series of questions about six aspects of their health care, as well as which of these aspects would be important to discuss with their pharmacist and what type of relationship they currently have/desire with their pharmacist. Results indicated that patients most commonly use their pharmacist for two aspects of their health care: drug interaction information (65%) and adverse effect information (56%). Fewer patients use their pharmacist for the four other aspects of their care: seizure frequency (13%), antiepileptic drug adherence (27%), medication profile (39%), and impact of their disease on their lifestyle (27%). Many patients want their pharmacist to be more involved in their health care, especially regarding drug interactions (76%), discussing adverse effects (74%), and maintaining a complete medication profile (61%). Patients also desired that their pharmacist communicate with their epileptologist about drug interactions (69%) and adverse effects (64%). Although many patients reported having a good relationship with their community pharmacist, a large concern was lack of privacy for holding conversations and lack of desire to pay for such pharmacy services if available. Overall, these results indicate that the majority of patients with epilepsy do not use their pharmacists to their full potential, yet certainly desire to do so, especially regarding drug interactions and adverse effects. Both pharmacists and patients should strive to form better partnerships that would allow them to take advantage of existing opportunities to enhance patient outcomes. Copyright 2009 Elsevier Inc. All rights reserved. Seizure emergency plans: Patient results from a cross-sectional epilepsy survey Guidance for seizure emergency plans exists, although their impact and extent of use in patients with epilepsy are undetermined. This study’s primary purpose was to measure the estimated use and content of seizure emergency plans. Secondary objectives included measuring: disease severity, quality of life, productivity, and adherence among patients with and without a plan. An online survey was conducted among 408 patients with epilepsy (ages 18–64) who took one or more antiepileptic drugs. Only 30% of patients reported having a plan, which included avoiding injury, notifying a physician, resting/relaxing, and seeking emergency assistance. Those with a plan were more likely to have experienced more seizures in the past year, to have missed school/work, to have incurred injury, to have visited the ER, to have been hospitalized, to fear additional seizures, and to have lost a job. Seizure emergency plans appear to be reserved for adults with more severe disease, but there may be clinical benefits to developing a plan for all adult patients with epilepsy. Copyright 2009 Elsevier Inc. All rights reserved. Seizures in the elderly: Impact on mental status, mood, and sleep Comorbidities of epilepsy have not been well explored in the elderly. Herein, we examined mental status, mood, and sleep in elderly patients with epilepsy, compared with age- and gender-matched community controls without epilepsy from the Einstein Aging Study. Testing included a mental status test, the Blessed Information Memory and Concentration (BIMC) test; Prime-MD Patient Health Questionnaire (PHQ) Depression and Anxiety Modules; and Medical Outcomes Study Sleep Scale. Persons with epilepsy (n = 31) had higher mean BIMC scores than controls (n = 31, BIMC 6.3 vs.1.2, P < 0.0001). Mean PHQ Depression scores were higher for cases than controls, indicating more depressive symptoms (4.2 vs 0.8, P = 0.006); six cases (18%) and no controls met screening criteria for depression. Mean PHQ Anxiety scores were also higher for cases than controls (3.7 vs 0.0, P = 0.001). Cases had poorer sleep scores in the categories of somnolence (P = 0.009) and shortness of breath/headache (P = 0.021). Thus, comorbidities of epilepsy in this elderly population included decreased mental status, a higher prevalence of depression and anxiety, and poorer sleep health when compared with agemates without epilepsy. Mental status impairment was not related to antiepileptic medication or mood disturbance. Further investigation will explore these associations prospectively. Copyright 2009 Elsevier Inc. All rights reserved. Sexual quality of life in epilepsy: Correlations with sex hormone blood levels Seventy-nine consecutive inpatients of an epilepsy center (34 women, 45 men) who had either generalized epilepsy, temporal lobe epilepsy, focal epilepsy of other origin, or no epilepsy completed the Derogatis Interview for Sexual Function—Self-Report Inventory. Quantitative assessments of blood levels were performed for prolactin, total testosterone, sex hormone-binding globulin, estradiol, dehydroepiandrosterone sulfate, luteinizing hormone, and follicle-stimulating hormone. In men, increasing sex hormonebinding globulin levels and duration of epilepsy decreased sexual quality of life. Sex hormone-binding globulin level in men was related to enzyme-inducing antiepileptic drugs and age. In women, we found no associations between blood hormone levels and sexual quality of life. Our results suggest that sexual quality of life is affected by sexual hormone blood levels in men, but not in women with epilepsy. Avoiding enzyme-inducing antiepileptic drugs may lower the risk of raised sex hormone-binding globulin levels and, thus, of lowered sexual quality of life in men with epilepsy. Copyright 2009 Elsevier Inc. All rights reserved. This is a prospective study of a consecutive series of children undergoing epilepsy surgery. The main aims were to evaluate the heterogeneity with respect to psychopathology and IQ, and to use a global assessment scale (Children’s Global Assessment Scale [CGAS]) to evaluate psychosocial functioning. Clinical neuropsychiatric and neuropsychological assessments were made at baseline and at the 2-year followup in 24 patients, and changes were analyzed at an individual level. Psychiatric disorders (mainly attention deficit hyperactivity disorder and/or autism spectrum disorders) were found in 17 of 24 at some point. All except one child with psychiatric diagnoses before surgery still had at least one diagnosis at follow-up. Intellectual ability remained stable in the majority of cases, both in individuals with and in individuals without mental retardation. The CGAS illustrated the consequences of the extensive comorbidity in this cohort. The behavioral problems had been undiagnosed despite parental concern in many cases, indicating an unrecognized need for services for children with drug-resistant epilepsy. Copyright 2009 Elsevier Inc. All rights reserved. Among the psychiatric comorbid conditions in children and adolescents with epilepsy, depression and anxiety disorders require further attention because they carry the risk of reduced quality of life and life-threatening complications (e.g., suicide). Research in recent years has shed light on both the prevalence of emotional problems in youth with epilepsy and the safety and efficacy of treatment options. A number of challenges exist in treating patients with epilepsy. This is particularly true when seizures are difficult to control and medication regimens are more complex. Some pharmaceutical options may provide assistance with both seizures and emotional distress, but care is needed when considering such treatment approaches. In addition, integration of mental health professionals into the care of patients is necessary when cases are complicated and risk factors are high. Thorough methods to accurately diagnose emotional conditions and regular monitoring of symptoms can help prevent serious problems that can negatively affect the success of children and adolescents in everyday life. Collaboration between disciplines offers the best hope for early identification and treatment of these conditions. Copyright 2009 Elsevier Inc. All rights reserved. What is it like to receive a diagnosis of nonepileptic seizures? The aim of this qualitative study was to provide insight into the experience of receiving the diagnosis of nonepileptic seizures (NES) from the patient’s perspective. Semistructured interviews were conducted with eight patients who had received the diagnosis of NES over the preceding 6 months. All participants were on a waiting list for psychological treatment. Verbatim records of the interviews were analyzed using interpretative phenomenological analysis (IPA). Six main themes emerged from the data (‘‘the experience of living with nonepileptic seizures”, ‘‘label and understanding”, ‘‘being left in limbo land”, ‘‘doubt and certainty”, ‘‘feeling like a human being again”, and ‘‘emotional impact of diagnosis”). An ability to integrate the diagnosis into a personal narrative was key to participants’ acceptance of the diagnosis. The communication of the diagnosis left some participants feeling distressed. The results suggest that patients need more time and resources to understand the diagnosis and more support after they have received it. Copyright 2009 Elsevier Inc. All rights reserved. Patient-perceived risk associated with epilepsy and its medication treatment Regardless of the expert advice of health care practitioners, it is ultimately the patient’s decision how to best manage his or her condition. This decision can be influenced by the perceived risk of both the disease and its treatment. The objective of this study was to develop a survey to evaluate perceived risk associated with epilepsy and its medication treatment. Risk was evaluated in five domains: performance, financial, social, psychological, and physical. A 40-item patient-perceived risk questionnaire was developed and administered to patients at one university-affiliated epilepsy clinic. Pearson correlation and regression analysis was used to identify significant components of overall perceived risk. A total of 64 patients completed the survey. Performance and physical risk significantly explained 34% of the variance in overall perceived risk associated with epilepsy. The overall perceived risk associated with the treatment of epilepsy was explained by performance, physical, psychological, and social risks (r2 = 0.386). Thus, the treatment of epilepsy poses more challenges for patients to maintain their lifestyle than the disease itself. Copyright 2009 Elsevier Inc. All rights reserved. Children and parents evaluate the child’s quality of life (QOL) from their own perspectives; therefore, responses may differ, especially in abstract domains. We examined differences between self- and proxy-reported QOL of children with epilepsy. Children with active epilepsy (N = 375) and their parents (N = 378) separately completed the CHEQOL-25, a condition-specific QOL measure. The intraclass correlation coefficient was used to determine interrater agreement. Concordance on the Total CHEQOL-25 was 0.45 (P < 0.01). Discrepancies were greatest for the subscales of Secrecy (0.24, P < 0.01) and Present Concerns (0.32, P < 0.01). School placement correlated with discrepancy in the Intrapersonal/Emotional subscale (r = 0.19, P < 0.05), and the child’s age at testing correlated with discrepancy of the Total measure (r = 0.15, P < 0.01). This study demonstrates that parent perspectives alone are insufficient to measure their child’s QOL. The CHEQOL-25 is a practical tool, with complementary parent and child versions, which can be used to determine health-related quality of life in children with epilepsy. Copyright 2009 Elsevier Inc. All rights reserved. Seizure response dogs: Evaluation of a formal training program Evidence supporting seizure-related behaviors in dogs is emerging. The methods of seizure response dog (SRD) training programs are unstudied. A standardized survey was retrospectively applied to graduates of a large SRD program. Subjective changes in quality of life (QOL) parameters were explored. Data were captured on animal characteristics, training methods, response and alerting behaviors, effects on seizure frequency, and accuracy of epilepsy diagnosis. Twenty-two patients (88%) participated (median age = 34, range = 12–66, 73% female). Most had childhood-onset epilepsy (87%) that was refractory with averages of 36 seizures/month and 4.8medications failed.All had neurologist-confirmed epilepsy,most beingsymptomatic partial (64%). SRD behaviors were reliable, including emergency response system activation in 27%. All reported SRD-related QOL improvements (major 82%, moderate 18%) across multiple parameters. Spontaneous alerting behavior developed in 59%. That SRDprogramsmay select genuine epilepsy patients, instill valuable assistance skills, and generate meaningful QOL improvements supports further seizure dog research. Copyright 2009 Elsevier Inc. All rights reserved. An evaluation of self-management behaviors and medication adherence in patients with epilepsy Comprehensive treatment of epilepsy involves many facets including self-management behaviors. The primary purpose of this study was to characterize the self-management behaviors of our patients. Additionally, we wanted to assess if the behaviors differed depending on the level of seizure control. Adult patients with epilepsy were recruited for this cross-sectional study. We used two previously validated scales to assess various self-management behaviors and collected clinical data. Our sample consisted of 50 patients (23 women). The mean overall Epilepsy Self-Management Scale (ESMS) question score was 3.72 ± 0.41. The mean question scores on the ESMS subscales Medication Management, Information Management, Safety Management, Seizure Management, and Lifestyle Management were 4.4, 2.7, 3.9, 4.0, and 2.6, respectively. Information Management and Safety Management subscale scores were higher in the patients continuing to have seizures. Based on the Morisky scale, patients fell into either the low (n = 2), medium (n = 27), or high (n = 21) medication-taking behavior category. Self-management skills, beyond medication-taking behaviors, should be emphasized during patient interactions. Copyright 2009 Elsevier Inc. All rights reserved. From the 15th century to the present day, Christian art has portrayed people who suffer from epilepsy as attributes in illustrations of Saint Valentine (SV). The objective of our study was to interpret the works of art from a modern epileptological perspective on the basis of a collection of portrayals of SV in Europe that was as comprehensive as possible. The people depicted as attributes were analyzed with respect to their age, gender, social status, and possible seizure semiology. Three hundred forty-one illustrations of SV from Austria, Belgium, Croatia, Czech Republic, France, Germany, Hungary, Ireland, Italy, Luxembourg, Poland, Scotland, Slovakia, and Switzerland were systematically analyzed. Irrespective of the age of the work of art, among the 143 pictures of people with possible epilepsy characteristics, there were more males than females from various levels of society. As far as could be interpreted, there were 17 infants, 35 children, 7 adolescents, and 84 adults. With respect to possibe seizure semiology, infantile spasms (n = 10), atonic seizures (n = 13), tonic seizures (n = 53), absences (n = 2), psychogenic seizures (n = 4), and postictal or undefinable states (n = 61) were differentiated in a subjective assessment. Despite the fact that from a modern perspective, the 15th to 20th centuries in Europe seemed to be dominated by a rather superstitious attitude toward epilepsy, there is striking accuracy in the detail of the semiology in many of the historic portrayals, and a well-founded knowledge of epilepsy is apparent. Copyright 2009 Elsevier Inc. All rights reserved. A survey was developed to gather information from both patients with epilepsy and community pharmacists on the issue of antiepileptic drug (AED) formulation switching, which includes brand to generic, generic to brand, and generic to generic. Data were obtained from 82 patients (or parents of patients) with epilepsy and 112 community pharmacists. More than 92% of patients and 85% of pharmacists agreed that switching between forms of the same AEDs may cause an increase in seizures or adverse effects. More than two-thirds of our patient sample reported having problems with formulation switching; many also reported knowing other patients with problems. Just more than half (51%) of the pharmacists knew of patients who have described problems when they have changed AED formulations. Less than 50% of both populations knew that problems resulting from formulation switching should be reported as adverse drug events to the FDA. Not many pharmacists and far fewer patients use MedWatch to report these problems. We conclude that both patients with epilepsy and pharmacists are underinformed and underinvolved with reporting adverse drug events. Copyright 2009 Elsevier Inc. All rights reserved. Articles Posted on February 7, 2008: Epilepsy surgery after age 60Data from seven patients 60 years of age and older who underwent temporal lobectomy were reviewed. Outcome was comparable to younger patients. Despite the small number of patients and retrospective nature of the study, the data support the efficacy and safety of temporal lobectomy in this age group. Copyright 2007 Elsevier Inc. All rights reserved. Epilepsy myths: Alive and foaming in the 21st century Many myths are perpetuated and reinforced in the portrayal of fictional characters with epilepsy in films and on television. Common cinematic treatment myths include the necessity for immediate medical intervention in the form of an ambulance crew to stop a seizure and the placing of an object in the seizing person’s mouth to prevent the person from choking on her or his tongue. Other misrepresentations include excessive ‘‘foaming’’ at the mouth during a seizure and frequent violence. We conducted an Internet-based survey to examine the prevalence of belief in these myths in the United Kingdom. We received 4605 valid responses. People who knew someone with epilepsy were significantly less likely to subscribe to all the myths than were those who had no personal knowledge of epilepsy. Seeing seizures in public appears to improve knowledge regarding appropriate first aid procedures, but does not have an impact on myths surrounding the presentation of a seizure. These results are discussed in relation to the ‘‘we see what we expect to see’’ phenomenon in relation to stereotypes surrounding epilepsy. Copyright: 2007 Elsevier Inc. All rights reserved. The differential effect of epilepsy labels on employer perceptions: Report of a pilot study A multimethod pilot study is described in which employers’ and human resource professionals’ perceptions of three labels used for epilepsy—epilepsy, seizure disorder, and seizure condition— were explored. Ninety-three participants were presented with a list of 10 chronic conditions or disabilities, including one of these epilepsy labels, and asked to rank-order the likelihood that a person with each condition would be hired for an assembly/production position. The participants also ranked cover letters from fictional applicants for a customer service representative position. The fictional applicants disclosed their condition using one of the three epilepsy labels. The participants then ranked which applicant would most likely be hired. Participants were also asked whether applicants should disclose their disability in a cover letter. Rasch and v2 analyses were used to analyze the results. Findings suggest that epilepsy was more positively perceived than the other two labels. Almost all of the participants stated that applicants should not disclose their disability in a cover letter. The results have important implications for employment seeking and disclosure practices. Copyright. 2007 Elsevier Inc. All rights reserved. The effect of seizure severity on quality of life in epilepsy Seizure severity is an important aspect of epilepsy. The relationship between seizure severity and quality of life in epilepsy, however, has been incompletely explored. With a data set of 118 women from the baseline phase of a clinical treatment trial, the relationship between seizure severity and aspects of quality of life was evaluated. Two domains of the Quality of Life in Epilepsy-31 (QOLIE-31) correlated highly significantly with seizure severity: Seizure Worry (r = _0.265, P = .004) and Social Functioning (r = _0.280, P = 0.002). Two additional domains were significantly correlated: Overall Quality of Life (r = _0.210, P = 0.023) and Cognitive (r = _0.209, P = 0.024). When the potentially confounding effect of depression, measured by the Beck Depression Inventory, was controlled for, the regression of seizure severity with QOLIE-31 Seizure Worry remained significant (P = 0.006, R2 = 0.153), as did the regression with QOLIE-31 Social Functioning (P = 0.002, R2 = 0.184) and the regression with QOLIE-31 Cognitive (P = 0.037, R2 = 0.30). These findings indicate that severe and potentially injurious seizure behaviors contribute to anxiety and socially avoidant behavior for persons with intractable epilepsy. Copyright 2007 Elsevier Inc. All rights reserved. Assessing the true learning needs of health care professionals in epilepsy care This needs assessment, initiated by the American Epilepsy Society (AES) in cooperation with AXDEV Group Inc. (AXDEV), used a mixed-method approach to explore the educational and clinical practice needs of health care professionals in epilepsy care and to identify significant barriers to caring for people with epilepsy. The multiphase assessment began with key informant interviews with AES educational leaders. In Phase II, 26 stakeholders, including epileptologists, neurologists, professionals in epilepsy care, and people with epilepsy, shared their experiences in epilepsy care during four focus groups at the AES annual meeting. In Phase III, a quantitative online survey based on Phase II results was distributed to 228 respondents, including epileptologists (n = 84), neurologists (n = 55), professionals in epilepsy care (n = 69), and others (n = 20). Results of the comprehensive analysis of Phase III quantitative data are presented here. They reveal the unmet needs of health care professionals in this therapeutic domain and are discussed in terms of their implications for epilepsy care. Copyright 2007 Elsevier Inc. All rights reserved. Assessment of quality of life among the elderly with epilepsy As the elderly represent the most rapidly growing population in the United States, it is critical that physicians are capable of managing their chronic illnesses, including epilepsy. Optimal treatment of epilepsy integrates an understanding of health-related quality of life (HRQOL), yet limited information is available to guide HRQOL issues among the elderly. This study found that seniors with epilepsy do not have poorer HRQOL compared with general epilepsy populations. However, when compared with general populations without epilepsy, seniors with epilepsy report a significantly lower HRQOL across all domains. Multiple factors may uniquely affect HRQOL among elderly populations with epilepsy: aging, comorbid conditions, and epilepsy variables. However, to our knowledge, no one instrument addresses all of these aspects. The development of HRQOL instruments specifically for an elderly population with epilepsy may be useful and needed. Copyright 2007 Elsevier Inc. All rights reserved. As individuals directly impacted by their experience of epilepsy and others’ responses to it, epilepsy patients’ opinions about education and awareness issues are needed. A community-based participatory approach was used to develop a survey of public and patient attitudes and perceptions about epilepsy, which was administered to persons with epilepsy. The majority of the 165 respondents (34% response rate) indicated they perceive misperceptions and stigma related to epilepsy in the general public, which they thought could be ameliorated through educational interventions. Respondents indicated potential avenues of educational intervention for the general public as well as for those with epilepsy, with recommended content and intervention type depending on target audience. The community-based participatory research process and the patients’ perceptions gathered through the resulting survey indicate potential activities for overcoming stigma and increasing education and awareness related to epilepsy. Copyright 2007 Elsevier Inc. All rights reserved. Parents of children with enduring epilepsy: Predictors of parenting stress and parenting Objective:The goals of the work described here were (1) to predict parenting stress and parenting from stressors, resources, and parental coping behaviors in parents of children with epilepsy, and (2) to determine whether parenting stress mediates the effects of these predictors on parenting. Sociodemographic correlates of health-related quality of life in pediatric epilepsy In most chronic conditions, better health-related quality of life (HRQOL) is associated with higher socioeconomic status (SES) and ethnic majority status, with disadvantaged groups typically reporting lower HRQOL. In 163 children with intractable epilepsy, we evaluated the relationship between HRQOL and a broad spectrum of demographic variables (SES, parental education, gender, age, marital status, family size, and ethnic and linguistic status), in relation to known neurological and behavioral correlates of HRQOL. No demographic variable was found to be related to child HRQOL, except for marital status, where children from divorced/separated parents had lower HRQOL. However, marital status was not uniquely predictive of HRQOL when neurological and behavioral variables were taken into account. Exploratory analyses indicated that children of separated/divorced parents were more likely to have early epilepsy onset, lower adaptive/developmental levels, and worse seizure frequency, suggesting that severe epilepsy may be a risk factor for marital stress. In sum, contrary to research in other chronic conditions, sociodemographic variables in pediatric epilepsy were weak predictors of HRQOL in comparison to neurological and behavioral variables. The results are discussed with respect to epilepsy-specific determinants of HRQOL. Copyright: 2007 Elsevier Inc. All rights reserved. Unmet mental health needs in pediatric epilepsy: Insights from providers Eighteen pediatric neurologists and 18 pediatricians completed a 5-point Likert scale questionnaire on their knowledge of, attitudes toward, and management of the behavioral, cognitive, and psychosocial aspects of pediatric epilepsy, before and after a lecture on this topic. They also responded to questions about possible barriers to mental health care of children with epilepsy. The brief educational intervention modified the knowledge/attitudes of pediatricians compared with pediatric neurologists on the impact of epilepsy on behavior and cognition in children with epilepsy. However, there were no between-group differences in how providers perceived their competence to assess behavioral and cognitive comorbid conditions in pediatric epilepsy. Responses to open-ended questions suggested insufficient mental health coverage for and expertise on pediatric epilepsy, resistance of mental health clinicians to treat children with epilepsy, and the stigma of mental health as possible barriers to mental health care in children with epilepsy. In addition to the need for provider education about the behavioral and cognitive comorbid conditions of pediatric epilepsy, these findings emphasize the importance of examining alternative routes to increasing mental health care for children with epilepsy. Copyright: 2007 Elsevier Inc. All rights reserved. A cross-sectional cohort of 82 cognitively normal children with epilepsy attending the pediatric neurology clinic, who were aged 6–17 years and who had a similarly aged sibling without seizures or cognitive delay, were identified. The parent was asked to complete the Family Assessment Measure III (FAM-III) as well as the Child Behavior Checklist (CBCL) for both the child with epilepsy and his or her sibling. The Overall Rating Score on FAM-III did not differ significantly from the normative mean, although families scored significantly better on the Involvement subscale and significantly worse on the Role Performance subscale. Moderate correlations were found between competence and behavior problems and family function in both children with epilepsy and their siblings. In families functioning at the highest level, both cohorts did well. In those at the lowest level, approximately half of the children in either cohort had problems. For average functioning families, behavior and competence issues were more frequent in children with epilepsy than their siblings. Copyright 2007 Elsevier Inc. All rights reserved. Attention-deficit/hyperactivity disorder (ADHD) in children with epilepsy is a common source of impairment. Based on review of Medline indexed articles, meeting abstracts, and data requested from drug manufacturers, a summary of evidence that might guide treatment and research is presented. Methylphenidate (MPH) has shown high response rates and no increase in seizures in small trials. However, low baseline seizure rates, small numbers of subjects, and short observation periods limit the power of these studies to detect increases in seizure risk. Although longer-term effects of MPH and its effects in children with frequent seizures need to be studied, the evidence available at this time best supports use of MPH for the treatment of ADHD not amenable to changes in antiepileptic drugs or improvements in seizure control. This treatment should be part of a biopsychosocial approach. Other agents show promise. Preclinical, retrospective and open-label studies on amphetamines and atomoxetine support undertaking randomized controlled studies of these agents in patients with ADHD plus epilepsy. In contrast, additional data on guanfacine and modafinil should be gathered before undertaking randomized controlled studies with these agents. Copyright: 2007 Elsevier Inc. All rights reserved. Articles Posted on August 16, 2007: Children with seizures exhibit preferences for foods compatible with the ketogenic diet Although highly effective for the treatment of intractable epilepsy, the ketogenic diet is not always included in the treatment option hierarchy presented to families, in part due to perceptions that children will find the high-fat/low-carbohydrate regimen unpalatable. This study assessed if children with seizures exhibit food preferences compatible with the diet, as well as if caregivers were accurate in predicting preferences. Children aged 2–17, with (n = 29) and without (n = 30) a history of seizures, participated in a paired choice food preference assessment while parents estimated child preferences verbally. Children with seizures exhibited significantly higher preferences for fat versus carbohydrate foods compared with controls, and parents demonstrated low accuracy. Future studies could use similar assessment methods to prospectively track whether such preferences predict diet compliance and/or efficacy. Research into the underlying metabolic basis for this preference and possible related neurophysiological mechanisms in seizure etiology and treatment is warranted. Copyright 2007 Elsevier Inc. All rights reserved Objective.The purpose of this study was to examine the extent to which children’s attitude toward epilepsy mediates the relationship between perceived stigma and the mental health outcomes of self-concept, behavioral problems, and social competence. Method.Subjects were 173 youth aged 9–14 who had been diagnosed and treated for epilepsy for at least 6 months. A secondary data analysis from a larger study was completed to test if the children’s attitude mediated the relationship between stigma and mental health outcomes using multiple regression. Results.Children’s attitude was found to mediate the relationships between stigma and self-concept and behavior problems, respectively. In contrast, attitude did not mediate the relationship between stigma and social competence. Conclusions.Results suggest that enhancing a more positive attitude toward having epilepsy might |
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