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PubMed1997

Comparative epidemiology of epilepsy in Pakistan and Turkey: population-based studies using identical protocols.

PURPOSE: To determine comparative prevalence rates, demographics, phenomenology, seizure classification, presumptive etiology, treatment status, and selected socioanthropological aspects of epilepsy in Pakistan and Turkey. METHODS: A population-based, cross-cultural comparative study of epilepsy was designed with identical protocols to be performed simultaneously in Pakistan and Turkey. The essential feature of the design was an unselected population, with reference to their previous medical contact, and use of standardized International Community-Based Epilepsy Research Group (ICBERG) protocols to assess cross-cultural differences. RESULTS: In all, 24,130 persons in Pakistan and 11,497 persons in Turkey (both urban and rural, of all ages and both sexes) were studied. The crude prevalence rate of epilepsy was 9.98 in 1,000 in Pakistan and 7.0 in 1,000 in Turkey (14.8 in 1,000 in rural and 7.4 in 1,000 in urban areas of Pakistan; 8.8 in 1,000 in rural and 4.5 in 1,000 in urban areas of Turkey). In both countries, epilepsy was twice as prevalent in rural areas than in urban areas. Mean age of onset of epilepsy was 13.3 years in Pakistan and 12.9 years in Turkey. Overall frequency of seizure types was similar in both countries, with no urban/rural differences. The frequency distribution in Pakistan and Turkey, respectively, was as follows; generalized tonic-clonic, 80.5 and 65.4%; simple partial, 5 and 7.4%; complex partial, 5 and 12.3%; generalized absence, 0.8 and 4.9%; tonic and atonic, 5.8 and 3.7% each; and myoclonic, 5.8 and 1.2%. A putative cause for the epilepsy could be attributed in 38.4% of cases in Pakistan and 35.7% of cases in Turkey. Only 3% of patients in Pakistan, but 71% of patients in Turkey, believed that their illness was due to supernatural causes. The treatment status was very poor. In Pakistan, 27.5% of people with epilepsy in urban areas and 1.9% of people with epilepsy in rural areas were receiving antiepileptic drugs (AEDs) at the time of the survey. In, Turkey 30% of patients were receiving AEDs (marginally higher in rural areas). CONCLUSIONS: The prevalence of epilepsy is slightly higher in Pakistan than in Turkey; some marginal differences in age and sex distribution, are not statistically significant. The results are comparable to those in Ecuador, where the same epidemiologic protocol was used.

Adolescent↗
PubMed1999

Risk factors for poor health-related quality of life in adolescents with epilepsy.

PURPOSE: To examine potential risk factors for poor health-related quality of life (HRQOL) among adolescents with epilepsy by using the newly developed QOLIE-AD-48. Risk factors were derived from sociodemographic, social, academic, and epilepsy- and health-related domains. METHODS: The QOLIE-AD-48 was administered to 197 English-speaking adolescents (age 11-17 years from >20 sites in the United States and in Canada). The self-report instrument yields an overall HRQOL score and eight subscale scores. Other data were obtained from family interviews, physician reports, and health records. Multiple regression analyses were conducted to study risk factors for impairment of HRQOL. RESULTS: Older adolescents (age 14-17 years), those with more severe epilepsy and more symptoms of neurotoxicity, and those living in households with lower socioeconomic status were more likely to report poor overall HRQOL. Risk factors in the eight HRQOL domains were found as follows: (a) Epilepsy Impact: older age in adolescence, more severe epilepsy and neurotoxicity, more hospitalizations during the past year, and fewer hours of extracurricular activities; (b) Memory and Concentration: longer duration of epilepsy, special education classes, and history of repeating a grade in school; (c) Attitude Toward Illness: older age, female gender, and more severe epilepsy and neurotoxicity; (d) Social Support: younger age, male gender, and fewer hospitalizations in the last year; (e) Stigma: lower socioeconomic status and special-education classes; and (f) Health Perceptions: older age, female gender, and lower socioeconomic status. None of the factors examined was significantly associated with HRQOL in (g) Physical Functioning or (h) School Behavior subscales. CONCLUSIONS: We identified several risk factors for poor HRQOL outcomes in adolescents with epilepsy. Age, increased seizure severity, and neurotoxicity were most consistently associated with poor HRQOL across domains. Older adolescents, independent of epilepsy severity, reported worse overall HRQOL than did their younger counterparts. Older adolescents also were more likely to perceive a greater negative impact on life and general health, and had more negative attitudes toward epilepsy. Adolescent boys and girls may show different sensitivities to various quality-of-life domains.

Achievement↗
PubMed2000

Social aspects of epilepsy in the adult in seven European countries. The RESt-1 Group.

PURPOSE: The social implications of epilepsy are ill-defined, and there are no comparative findings from different countries. A multicenter cohort study has recently been completed on the risk of morbidity and accidents. The main social issues in the study population (patients with epilepsy and control subjects) are investigated and correlated to the clinical features of the disease. METHODS: Seven hundred six adult patients with idiopathic or remote symptomatic epilepsy and 662 matched controls without epilepsy were enrolled by secondary and tertiary centers in seven European countries (Italy, Germany, Spain, the Netherlands, England, Portugal, and Russia). At entry, patients and controls were interviewed, and data were collected on social variables (education, current occupation, marital status, driving, involvement in sports, and insurance). The main clinical features of epilepsy (seizure types, frequency and timing, disease duration, and syndrome) were also recorded. RESULTS: The sample included 690 men and 678 women aged 18 to 86 years. The level of education (mostly basic or high school) was slightly higher among patients with epilepsy. More patients than controls were single (56% versus 50%) or unemployed (18% versus 13%). Fewer patients than controls held a driver's license (44% versus 67%) or practiced sports (30% versus 41%). The distribution of each social variable varied significantly across countries, but with few exceptions, the differences between patients and controls were fairly similar. Based on multivariate analysis, for patients with epilepsy the odds ratio for driving was 0.27, and the corresponding odds ratios for sports involvement, better education, better occupation, and insurance were 0.59, 1.30, 0.60, and 1.49. Among patients with epilepsy, social variables were correlated to seizure remission and selected clinical features. CONCLUSIONS: Comparative findings from different European countries support the concept that epilepsy has a considerable impact on driving and-to a lesser extent-on education, occupation, leisure activities, and insurance. The social implications of epilepsy in this sample are partly related to its severity and clinical features.

Adolescent↗
PubMed2000

Risk of epilepsy in long-term survivors of surgery for aneurysmal subarachnoid hemorrhage: a population-based study in Iceland.

PURPOSE: Epilepsy is known to result from aneurysmal subarachnoid hemorrhage (SAH). There are no population-based estimates of the absolute risk or the duration for which this risk is elevated. We have conducted a population-based study in Iceland of the risk of epilepsy after a ruptured cerebral aneurysm to address these questions. METHODS: The index patients are all of the patients who presented with SAH caused by ruptured cerebral aneurysm in Iceland during an 11-year period (1958 to 1968) and survived more than 6 months. We determined the number of index patients who developed epilepsy. The observed number of cases of epilepsy was compared with that expected based on the incidence of epilepsy in Iceland. RESULTS: There were 44 index patients; 11 (25%) developed epilepsy, all within 4 years of the insult. Seven (70%) of 10 patients with acute symptomatic seizures (defined as seizures during the first 2 weeks after the hemorrhage) developed epilepsy (relative risk, 7.0; 95% confidence interval, 2.3-21.6). Epilepsy was more frequent in patients with severe neurological residua (48%) compared with patients without (20%) (relative risk, 2.5; 95% confidence interval, 0.9-6.3). CONCLUSIONS: The risk for epilepsy among survivors of SAH caused by ruptured cerebral aneurysm is substantially increased. Both acute symptomatic seizure and persistent neurological impairment are associated with a further increase in the risk of epilepsy.

Epilepsy↗
PubMed2000

How well can epilepsy syndromes be identified at diagnosis? A reassessment 2 years after initial diagnosis.

PURPOSE: Epilepsy syndromes can be identified very early in the course of a seizure disorder. It is unclear how accurate and resilient such early classifications are. We compared the classification of epilepsy syndromes made previously on the basis of information available at diagnosis with those made 2 years later in a cohort of children with newly diagnosed epilepsy. METHODS: Children (n = 613) were prospectively identified at the time of initial diagnosis by participating physicians in Connecticut between 1993 and 1997. Classification of epilepsy syndrome according to International League Against Epilepsy guidelines was made previously based on all relevant information available at diagnosis. All cases were reclassified again after 2 years of additional evidence had accumulated. The distributions of syndromes at diagnosis and at 2 years are compared and reasons for changes examined. RESULTS: After 2 years, syndromes remained the same in 86.3% of the cohort and changes occurred in 13.7% (n = 84). Evolution of the syndrome occurred in 24 children (3.9%), and rectification to the initial diagnosis occurred in 60 children (9.8%). The most common scenario for evolution of a syndrome was from West syndrome (n = 5), undetermined (n = 4), or symptomatic localization-related epilepsy (n = 3) to the Lennox-Gastaut syndrome. The most common rectification of initial classifications involved incompletely classified syndromes (cryptogenic localization-related and undetermined syndromes; n = 36). In a few instances, a fully specified syndrome was reclassified to another apparently unrelated syndrome. In these cases, initial information at diagnosis had been difficult to interpret. CONCLUSIONS: Epilepsy syndromes can, for the most part, be identified at the time of initial diagnosis. Two years later, rectifications were made in only 9.8% of cases, and most of these involved syndromes that represented incomplete classifications in the first place. Significant changes were rare. The International League Against Epilepsy classification of the epilepsies can be meaningfully applied in epidemiological studies of newly diagnosed pediatric epilepsy.

Age of Onset↗
PubMed2000

Significance of cerebellar atrophy in intractable temporal lobe epilepsy: a quantitative MRI study.

PURPOSE: To determine the incidence of cerebellar atrophy (CA) in patients with intractable temporal lobe epilepsy, whether any clinical factors are significantly associated with CA, whether CA is unilateral or asymmetric and whether this feature has any relationship to the side of epileptogenicity, and whether the presence of CA is related to epilepsy surgery outcome. METHODS: We developed a magnetic resonance imaging method of measuring the presurgical volumes of the cerebellar hemispheres of 185 patients who underwent temporal lobectomy for intractable epilepsy and of 80 control subjects. In addition, cerebellar volumes were normalized to the total brain volumes. CA was determined as being present when the measured volume was smaller than two standard deviations from the mean value found in control subjects. RESULTS: Both absolute and normalized cerebellar volumes were found to be significantly reduced in the epilepsy patients compared with the control subjects. Without normalization of the cerebellar volumes, CA was present in 25.9% of the epilepsy patients; with normalization, it was present in only 16.2%. The atrophy was symmetric between the cerebellar hemispheres, and there was no significant difference in volume between the hemisphere ipsilateral and the hemisphere contralateral to the side of the temporal lobectomy. The duration of epilepsy was significantly longer and the age at onset of epilepsy was younger in patients with CA than in those without CA. The presence of CA was not associated with the outcome of temporal lobectomy. CONCLUSIONS: CA is symmetric and common in patients with intractable temporal lobe epilepsy. However, the results suggest that the atrophy in one third of patients with CA also proportionately affects the cerebral hemispheres. The duration of epilepsy and the age at onset of epilepsy are associated with the occurrence of CA. Seizure control after temporal lobectomy is not influenced by the presence of CA.

Adult↗
PubMed2005

Analysis of genetically complex epilepsies.

During the last decade, great progress has been made in the discovery of genes that influence risk for epilepsy. However, these gene discoveries have been in epilepsies with Mendelian modes of inheritance, which comprise only a tiny fraction of all epilepsy. Most people with epilepsy have no affected relatives, suggesting that the great majority of all epilepsies are genetically complex: multiple genes contribute to their etiology, none of which has a major effect on disease risk. Gene discovery in the genetically complex epilepsies is a formidable task. It is unclear which epilepsy phenotypes are most advantageous to study, and chromosomal localization and mutation detection are much more difficult than in Mendelian epilepsies. Association studies are very promising for the identification of complex epilepsy genes, but we are still in the earliest stages of their application in the epilepsies. Future studies should employ very large sample sizes to ensure adequate statistical power, clinical phenotyping methods of the highest quality, designs and analytic techniques that control for population stratification, and state-of-the-art molecular methods. Collaborative studies are essential to achieve these goals.

Chromosome Mapping↗
PubMed2005

Mortality of epilepsy in developed countries: a review.

Mortality in people with epilepsy has been studied in many different populations. In population-based incidence cohorts of epilepsy with 7-29 years follow-up, there was up to a threefold increase in mortality, compared to the general population (standardized mortality ratios [SMR] ranged from 1.6 to 3.0). When studies include selected epilepsy populations where patients with frequent and severe seizures are more common, the mortality is even greater. Relative survivorship (RS) following the diagnosis of epilepsy was 91%, 85%, and 83% after 5, 10, and 15 years, respectively. In a population with childhood-onset epilepsy, RS was 94% and 88% after 10 and 20 years. The level of increased mortality is affected by several factors. In idiopathic epilepsy where the causes of seizures are unknown, the results are conflicting. There was no significant increase in mortality in studies from Iceland, France, and Sweden, a barely increased risk in a study from the United Kingdom, and a significantly increased risk in a study from the United States. In contrast, all studies report a significant increased mortality in remote symptomatic epilepsy (standardized mortality ratios [SMRs] ranging from 2.2 to 6.5). The highest mortality is found in patients with epilepsy and neurodeficits present since birth, including mental retardation or cerebral palsy (SMRs ranging from 7 to 50). Mortality is also affected by age, with the highest SMRs in children, the combined effect of low mortality in the reference population, and high mortality in children with neurodeficits and epilepsy. The highest excess mortality is found in the elderly, > or =75 years. A pronounced increase in mortality is found during the first year following the onset of seizures due to underlying severe diseases. The increased mortality remains in different studies 2-14 years following diagnosis. Most of the factors responsible for the increased mortality are related to the underlying disorder causing epilepsy with pneumonia, cerebrovascular disease, and neoplastic disorders (risk remains elevated when primary brain tumors are excluded), as the most frequently recorded causes. The most common direct seizure-related cause of death in adolescents and young adults is sudden unexpected death, which is 24 times more common than in the general population.

Adolescent↗
PubMed2005

Diffusion tensor imaging in late posttraumatic epilepsy.

PURPOSE: The main objective of this study was to use diffusion tensor imaging (DTI) to search and quantify the extent of abnormality beyond the obvious lesions seen on the T2 and fluid-attenuation inversion recovery (FLAIR) magnetic resonance images in patients with chronic traumatic brain injury (TBI) with and without epilepsy. METHODS: DTI was performed on 23 chronic TBI patients (with late posttraumatic epilepsy, n=14; without epilepsy, n=9) and 11 age-matched controls. The ratios of fractional anisotropy (FA) and mean diffusivity (MD) between the regions of interest beyond the T2/FLAIR-visualized abnormality and the corresponding contralateral normal-appearing region were calculated. FA and MD ratios were compared for relative changes in these parameters among the TBI subjects with and without epilepsy and controls. Tissue volumes exhibiting abnormalities on DTI also were measured in these patients. RESULTS: The mean regional FA ratio was significantly lower, whereas the mean regional MD value was higher in patients with TBI compared with controls. The mean regional FA ratio was significantly lower in TBI patients with epilepsy (0.57+/-0.059) than in those without epilepsy (0.68+/-0.039). Although the regional MD ratio was higher in TBI patients with epilepsy (1.15+/-0.140) relative to those without epilepsy (1.09+/-0.141), the difference did not reach statistical significance. The tissue volume with low FA value also was found to be higher in TBI patients with epilepsy than without. CONCLUSIONS: Severity of injury as predicted by the DTI-derived increased volume of microstructure damage is associated with delayed posttraumatic epilepsy in TBI patients. These findings could be valuable in predicting epileptogenesis in patients with chronic TBI.

Adolescent↗
PubMed2004

Predictive value of death certification in the case ascertainment of epilepsy.

OBJECTIVES: Death certificates are an unreliable source of information on cause of death, and mortality due to epilepsy can thus be underestimated. METHODS: We investigated people with epilepsy who had died, and attempted to identify factors that influence inclusion of epilepsy on the death certificate; eight factors were hypothesised and entered into a univariate logistic regression model. RESULTS: Epilepsy was on the death certificate of 16/243 (7%) people who had had epilepsy. Factors that influenced whether or not epilepsy appeared on the certificate were seizure frequency, antiepileptic drug treatment, cause of death, and certifying physician. Factors that did not seem to influence the inclusion of epilepsy were presence of convulsive seizures, occurrence of seizures during follow up, and age at death. CONCLUSIONS: We have estimated the degree of unreliability of death certificates (as currently used in the UK) as a source of information on cause of death in epilepsy. We have found that epilepsy may not appear on death certificates even if people had active epilepsy.

Adolescent↗
PubMed1998

Reduction in temporal N-acetylaspartate and creatine (or choline) ratio in temporal lobe epilepsy: does this 1H-magnetic resonance spectroscopy finding mean poor seizure control?

BACKGROUND: Proton magnetic resonance spectroscopy (1H-MRS) is a potentially useful tool in the in vivo investigation of brain metabolites in intractable temporal lobe epilepsy (TLE). Focal N-acetylaspartate (NAA) reductions have been correlated with mesial temporal sclerosis (MTS) in surgically resected epileptogenic foci. OBJECTIVE: To evaluate the abnormalities in the metabolites NAA, creatine+ phosphocreatine (Cr), and choline containing compounds (Cho) in the temporal lobe of medically refractory patients with temporal lobe epilepsy, seizure free patients with temporal lobe epilepsy, and normal controls. PATIENTS AND METHODS: Ten refractory patients, 12 seizure free patients with temporal lobe epilepsy, and 10 age matched normal controls were studied by 1H-magnetic resonance spectroscopy. All patients had consistently unilateral temporal EEG abnormalities and a normal brain MRI. Proton MR spectra were obtained from an 8 ml volume in the medial temporal lobes in patients with temporal lobe epilepsy (ipsilateral to EEG foci) and the normal controls. The signals measured were expressed in terms of NAA/Cr, NAA/Cho, and Cho/Cr. RESULTS: When compared with seizure free patients with temporal lobe epilepsy and normal controls, the 10 refractory patients with temporal lobe epilepsy had a lower mean (SEM) NAA/Cr ratio (1.65 (0.53) v 2.62 (0.60), and 2.66 (0.73); p<0.002 and p<0.006) and a lower mean NAA/Cho ratio (1.59 (0.79) v 2.83 (1.33) and 2.58 (0.67); p<0.02 and p<0.007). Furthermore, the two patients showing the lowest NAA/Cr ratios (1.47 and 1.73) in the seizure free group had had a past period of poor seizure control. CONCLUSIONS: There were reduced temporal NAA/Cr and NAA/Cho ratios, suggesting neuronal loss or damage, associated with past or present poor seizure control in the patients with temporal lobe epilepsy, but it does not exclude the possibility of a future complete seizure control (seizure free patients with temporal lobe epilepsy at the time of 1H-MRS). This study warrants further 1H-MRS investigation with a larger series of patients with temporal lobe epilepsy.

Adolescent↗
PubMed1991

Occupational aspects of epilepsy in the civil service.

Eighty five civil servants with epilepsy who were referred to the Civil Service Occupational Health Service over an 18 month period formed the study population. The reasons for these referrals and their outcomes have been analysed. The main reasons for referral were prolonged or frequent sickness absence, unsatisfactory work performance, epilepsy starting during employment, the discovery of undisclosed epilepsy, and for advice on working conditions. In 30 the outcome was medical retirement, although in only 15 was this due to epilepsy alone. Of the other 15, medical retirement was necessary in four because of the combination of epilepsy with another medical disorder, and in 11 because of a coincidental condition unrelated to their epilepsy. Only six out of 15 referred on account of epilepsy related sickness absence, and none of the 14 referrals due to epilepsy related unsatisfactory work performance resulted in early retirement. This reflected the invaluable role that the occupational physicians had in recognising where problems were due to poor control of the epilepsy or to the side effects of the antiepileptic medication and in arranging through general practitioners or hospital doctors for appropriate adjustment of the drug regimen. Nine of the 22 subjects who developed epilepsy during employment, however, were retired on medical grounds.

Absenteeism↗
PubMed2002

Negative symptoms in temporal lobe epilepsy.

OBJECTIVE: This study examined the frequency of negative and positive symptoms in nonpsychotic patients with temporal lobe epilepsy and the relationship of negative and positive symptoms to cognition, quantitative magnetic resonance imaging (MRI) volumetrics, and depression. METHOD: Eighty-four patients with temporal lobe epilepsy and 74 healthy comparison subjects were evaluated for negative and positive symptoms and underwent comprehensive neuropsychological evaluation, quantitative MRI volumetrics, and assessment of mood state and depression. RESULTS: Negative symptoms were significantly more prevalent in the patients with temporal lobe epilepsy (31%) than in the comparison subjects (8%). There was no difference between groups in the rate of positive symptoms. Although the epilepsy patients as a group exhibited generalized cognitive impairment relative to the comparison subjects, the epilepsy patients with negative symptoms performed significantly worse than patients without negative symptoms and comparison subjects across measures of nonverbal intelligence, visuoperception, speeded visuomotor processing, and memory. The epilepsy patients with negative symptoms exhibited significantly greater diffuse atrophy than the healthy comparison subjects and higher CSF volumes than the epilepsy patients without negative symptoms. The epilepsy patients with and without negative symptoms had statistically equivalent Beck Depression Inventory scores and lifetime history of mood disorders, including major depression. CONCLUSIONS: Negative but not positive symptoms were more prevalent in temporal lobe epilepsy patients than in healthy comparison subjects. Negative symptoms were independent of current and past depression and were associated with neuropsychological deficits exceeding the general cognitive morbidity associated with temporal lobe epilepsy and with quantitative MRI indices suggesting greater cerebral atrophy.

Adolescent↗
PubMed2004

Study of seizure and epilepsy in Chinese children in Hong Kong: period prevalence and patterns.

The Hong Kong Children's Seizure and Epilepsy Registry was set up for all children with a history of seizures or epilepsy followed up in the Epilepsy Clinic of the University of Hong Kong. The aim was to study the pattern of seizures and epileptic disorders in Chinese children. The objective was to study the period prevalence of epilepsy and the pattern of epilepsy in Chinese children. A prospective study of seizure and epilepsy in Chinese children was conducted from 1985 to 1997 in Hong Kong. The population census of 1997 was used to calculate the period prevalence of epilepsy in Chinese children. Altogether, 1103 children aged < 19 years at first assessment with epilepsy were included in the study. The period prevalence rate of epilepsy in 1997 (January to December) is estimated to be 4.5 per 1000 children aged < 19 years. The estimated period prevalence rate of children and adolescents with epilepsy in our children is 4.5 per 1000 children.

Adolescent↗
PubMed2004

Prevalence of epilepsy in Turkish children between the ages of 0 and 16 years.

The aim of this cross-sectional study was to determine the prevalence of epilepsy in Turkey among children between the ages of 0 and 16 years. The study population consisted of 24,773,569 children living in Turkey. Because the prevalence of childhood epilepsy is reported to be 0.001 to 1% in the literature, the sample size was determined as 48,260, with 0.05 error type I and 0.10 error type 2 (power 0.90), and the effect size was 2. With the cluster sampling method, samples were selected from cities, towns, districts, and villages, and 46,813 (97%) children were reached. The study questionnaire contained sections with individual informational questions and questions for the selection of suspected epilepsy cases and physical examination results. The epilepsy classification was designed according to the classification of the International League Against Epilepsy (ILAE). The prevalence of epilepsy was determined as 0.8%; 55.2% of the subjects with epilepsy were grouped as generalized, 39% as partial, and 5.8% as unidentified. Age, place of residence, route of delivery, place of delivery, and social and economic status had no statistically significant effect on the development of epilepsy. Male gender, preterm, and post-term delivery increased the risk of developing epilepsy. Early diagnosis and treatment of epilepsy, as well as the education of health workers and families, are very important.

Adolescent↗
PubMed2005

Treatment of pediatric epilepsy: expert opinion, 2005.

BACKGROUND: Childhood epilepsies are a heterogeneous group of conditions that differ in diagnostic criteria and management and have dramatically different outcomes. Despite increasing data on treatment of epilepsy, research findings on childhood epilepsy are more limited and many clinical questions remain unanswered, so that clinicians must often rely on clinical judgment. In such clinical situations, expert opinion can be especially helpful. METHODS: A survey on pediatric epilepsy and seizures (33 questions and 645 treatment options) was sent to 41 U.S. physicians specializing in pediatric epilepsy, 39 (95%) of whom completed it. In some questions, the experts were asked to recommend overall treatment approaches for specific syndromes (the order in which they would use certain strategies). Most of the questions asked the experts to rate options using a modified version of the RAND 9-point scale for medical appropriateness. Consensus was defined as a non-random distribution of scores by chi-square test, with ratings used to assign a categorical rank (first line/usually appropriate, second line/equivocal, and third line/usually not appropriate) to each option. RESULTS: Valproate was treatment of choice for symptomatic myoclonic and generalized tonic-clonic seizures except in the very young, with lamotrigine and topiramate also first line (usually appropriate). Zonisamide was first line only if the child also has myoclonic seizures. For initial monotherapy for complex partial seizures, oxcarbazepine and carbamazepine were treatments of choice, with lamotrigine and levetiracetam also first line. As initial therapy for infantile spasms caused by tuberous sclerosis, viagabatrin was treatment of choice, with adrenocorticotropic hormone (ACTH) also first line. As initial therapy for infantile spasms that are symptomatic in etiology, ACTH was treatment of choice, with topiramate also first line. As initial therapy for Lennox-Gastaut syndrome, valproate was treatment of choice, with topiramate and lamotrigine also first line. For acute treatment of a prolonged febrile seizure or cluster of seizures, rectal diazepam was treatment of choice. For benign childhood epilepsy with centro-temporal spikes, oxcarbazepine and carbamazepine were treatments of choice, with gabapentin, lamotrigine, and levetiracetam also first line. For childhood absence epilepsy, ethosuximide was treatment of choice, with valproate and lamotrigine also first line. For juvenile absence epilepsy, valproate and lamotrigine were treatments of choice. For juvenile myoclonic epilepsy in adolescent males, valproate and lamotrigine were treatments of choice, with topiramate also first line; for juvenile myoclonic epilepsy in adolescent females, lamotrigine was treatment of choice, with topiramate and valproate other first-line options. As initial therapy for neonatal status epilepticus, intravenous phenobarbital was treatment of choice, with intravenous lorazepam or fosphenytoin also first line. As initial therapy for all types of pediatric status epilepticus, lorazepam was treatment of choice, with intravenous diazepam also first line. For generalized tonic-clonic status epilepticus, rectal diazepam and fosphenytoin were also first line; for complex partial status epilepticus, fosphenytoin was also first line; and for absence status epilepticus, intravenous valproate was also first line. CONCLUSION: The expert panel reached consensus on many treatment options. Within the limits of expert opinion and with the understanding that new research data may take precedence, the experts' recommendations provide helpful guidance in situations where the medical literature is scant or lacking. The information in this report should be evaluated in conjunction with evidence-based findings.

Adolescent↗
PubMed2005

Efficacy and safety of topiramate in refractory epilepsy of childhood: long-term follow-up study.

This study aimed to evaluate the long-term efficacy and safety of topiramate in treating children with drug-resistant epilepsy. A multicentric, retrospective, open-label, add-on study was undertaken of 277 children (mean age 8.4 years; range 12 months to 16 years) affected by drug-resistant epilepsy. The efficacy was rated according to the seizure types and epilepsy syndrome. After a mean period of 27.5 months of treatment (range 24-61 months), 11 patients (4%) were seizure free and 56 (20%) had more than 50% reduction in seizure frequency. The efficacy of topiramate treatment was noted in localization-related epilepsy and in generalized epilepsy. In addition, in a group of 114 patients, we compared the initial efficacy (evaluated after a mean of 9 months of follow-up) and the retention at a mean of 30 months of topiramate with regard to loss of efficacy (defined as the return to the baseline seizure frequency). Fifty-five (48%) of 114 patients were initial responders. The retention at a mean of 30 months was 23 of 114 patients (20%), 4 of whom (3.5%) were still seizure free. A loss of efficacy occurred in 32 of the 55 initial responders (58%). It was prominent in patients with generalized epilepsy, such as symptomatic infantile spasms and Lennox-Gastaut syndrome, as well as in those with Dravet syndrome. By contrast, a well-sustained topiramate efficacy was noted among patients with localization-related epilepsy. Globally, adverse events were observed in 161 patients (58%) and were mainly represented by weight loss, hyperthermia, sedation, and nervousness, which, in most cases, disappeared after slowing titration or reducing the dosage of the drug. In conclusion, the present long-term study confirms that topiramate represents a useful drug effective in a wide range of seizures and epilepsy syndromes. Moreover, preliminary data seem to suggest that the efficacy of topiramate, when evaluated in the long-term perspective, is more sustained in localization-related epilepsy than in generalized epilepsy.

Adolescent↗
PubMed2005

General practitioner attitudes to the care of people with epilepsy: an examination of clustering within practices and prediction of patient-rated quality of care.

BACKGROUND: There is wide variation in the quality of care provided by primary care practices to individuals with chronic illnesses. Individual doctor attitudes and interest have been demonstrated to influence patient outcomes in some instances. Given the trend towards larger practices and part-time working, continuity of care is likely to fall and thus practice-based rather than individual general practitioner attributes and attitudes are likely to become increasingly important. The aim in this paper was to examine the extent to which individual general practitioner (G.P.) attitudes to the care of people with epilepsy cluster within practices and predict patient-rated quality of care. METHODS: The sample consisted of 1255 people with active epilepsy (a recent seizure or on anti-convulsant medication for epilepsy) and 199 GPs from 82 general practices. Measures of GP attitudes (a 17-item GP attitudes questionnaire) and patient-rated quality of epilepsy care were obtained. 1210 individuals completed initial questionnaires and 975 patients filled in final questionnaires one year later. Responses were achieved from 64 practices (83% of total) and 115 GPs (60% of total). RESULTS: 2 main factors were found to underlie GP attitudes to the care of people with epilepsy and these demonstrated clustering within practices "epilepsy viewed as a primary care responsibility" (Eigenvalue 3.98, intra-class correlation coefficient (ICC) 0.40), and "medication skills"(Eigenvalue 2.74, ICC 0.35). GP-rated scores on "epilepsy care being a primary care responsibility" were a significant predictor of patient-rated quality of GP care (p = 0.031). Other contributory factors were seizure frequency (p = 0.044), and patient-rated "shared decision making" (p = 0.022). CONCLUSION: Specific general practitioner attitudes to the care of people with epilepsy cluster within practices and are significantly associated with patient-rated quality of epilepsy care. It is important to take these findings into consideration when planning primary care interventions to ensure people with epilepsy receive the benefits of available medical and surgical expertise.

Attitude of Health Personnel↗