ORCID Profile
0000-0001-8958-3844
Current Organisations
Pukyong National University
,
Alfred Health
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Publisher: Wiley
Date: 27-01-2022
DOI: 10.1111/EPI.17172
Abstract: An important but understudied benefit of resective epilepsy surgery is improvement in productivity that is, people's ability to contribute to society through participation in the workforce and in unpaid roles such as carer duties. Here, we aimed to evaluate productivity in adults with drug‐resistant epilepsy (DRE) pre‐ and post‐resective epilepsy surgery, and to explore the factors that positively influence productivity outcomes. We conducted a systematic review and meta‐analysis using four electronic databases: Medline (Ovid), EMBASE (Ovid), EBM Reviews ‐ Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Library. All studies over the past 30 years reporting on pre‐ and post‐resective epilepsy surgical outcomes in adults with DRE were eligible for inclusion. Meta‐analysis was performed to assess the post‐surgery change in employment outcomes. A total of 1005 titles and abstracts were reviewed. Seventeen studies, comprising 2056 unique patients, were suitable for the final quantitative synthesis and meta‐analysis. Resective epilepsy surgery resulted in a 22% improvement in overall productivity (95% confidence interval [CI]: 1.07–1.40). The factors associated with increased post‐surgery employment risk ratios were lower pre‐surgical employment in the workforce (relative risk ratio [RRR] =0.34 95% CI: 0.15–0.74), shorter follow‐up duration (RRR = 0.95 95% CI: 0.90–0.99), and lower mean age at time of surgery (RRR= 0.97 95% CI: 0.94–0.99). The risk of bias of the included studies was assessed using Risk Of Bias In Non‐randomised Studies ‐ of Interventions and was low for most variables except ”measurement of exposure.” There is clear evidence that resective surgery in eligible surgical DRE patients results in improved productivity. Future work may include implementing a standardized method for collecting and reporting productivity in epilepsy cohorts and focusing on ways to reprioritize health care resource allocation to allow suitable candidates to access surgery earlier. This will ultimately benefit in iduals with DRE, their families, our communities, and the wider health care system.
Publisher: Elsevier BV
Date: 05-2014
DOI: 10.1016/J.MSARD.2013.11.002
Abstract: An 82-year old male, with no significant past medical history, presented with a subacute right foot drop in the setting of a 14-month history of generalised weakness, highly-responsive to steroids. Temporal artery and vastus lateralis biopsies were normal. Vasculitic screen and inflammatory markers were normal. Lumbar puncture revealed elevated cerebrospinal fluid (CSF) protein without oligoclonal bands. Visual evoked response (VER) was normal. Magnetic resonance imaging (MRI) of his lumbar spine showed compression of exiting L5 nerve root. He had three cerebral MRI scans spaced over the 12 month period, which showed a progressive increase of T2 and fluid attenuated inversion recovery (FLAIR) hyperintense lesions consistent with active demyelinating plaques. He was treated with intravenous methylprednisolone 1g daily for three days with a weaning regimen of oral prednisolone, resulting in a full return of power and a resolution of his right foot drop. He was diagnosed with late-onset multiple sclerosis (LOMS), and was treated with monthly natalizumab. A literature review of LOMS is discussed.
Publisher: BMJ
Date: 04-04-2019
Abstract: Almost 10% of people will experience at least one seizure over a lifetime. Although common, first seizures are serious events and warrant careful assessment and management. First seizures may be provoked by acute or remote symptomatic factors including life-threatening metabolic derangements, drug toxicity or structural brain lesions. An unprovoked first seizure may herald the onset of epilepsy and may be accompanied by medical and psychiatric illnesses. Accidents, injuries and death associated with first seizures are likely under-reported. The cognitive and emotional impact of first seizures is often neglected. Evaluation of a patient presenting with a first seizure requires careful history-taking and early specialist assessment, however optimal management strategies have not been extensively investigated. Further, advances in technology and the role of eHealth interventions such as telemedicine may be of value in the care of patients who have experienced a first seizure. This article reviews the impact and implications of first seizures beyond the scope provided in current guidelines which tend to focus on assessment and management. It examines the effect of first seizures on the well-being of patients assesses morbidity and premature mortality in first seizures and discusses current and future directions to optimise safety and health of people with first seizures, with a focus on adult patients. Recognition of these issues is essential to provide adequate care for people with first seizures.
Publisher: Elsevier BV
Date: 07-2014
DOI: 10.1016/J.JOCN.2013.10.035
Abstract: Upper limb amyotrophy may occur as an indirect consequence of various spinal disorders, including ventral longitudinal intraspinal fluid collection, Hirayama disease and high cervical cord compression. We present patients who suffer from each of these and review the literature on the three conditions with emphasis on the pathogenesis of amyotrophy. We propose that pathology some distance from the lower cervical spinal cord may affect normal venous drainage, resulting in venous congestion and reduced perfusion pressure which, in turn, could result in anterior horn cell dysfunction in all three disorders.
Publisher: Elsevier BV
Date: 11-2013
DOI: 10.1016/J.JOCN.2012.10.011
Abstract: A 73-year-old man, with a history of hypertension and left supraclavicular fossa arteriovenous malformation with multiple previous uncomplicated vessel embolisation procedures, presented with acute spastic quadriparesis and urinary retention following upper limb angiography and embolisation. There was no evidence of preceding infection or neurological disease prior to the event. Cerebrospinal fluid analysis was unremarkable. MRI of the cervical spine with a 1.5 Tesla magnet performed 13 hours from symptom onset revealed bilateral paramedian intramedullary T2-weighted signal change without gadolinium enhancement limited to the grey matter with corresponding diffusion restriction extending from C5-6 down to the mid-T1. The diagnosis of cervical spinal cord infarction (SCI) was made and the patient was given regular aspirin and atorvastatin. On follow-up at 3 months, there was modest improvement with respect to his quadriparesis and was walking unaided. An extensive literature review on the role of MRI in SCI is discussed.
Publisher: OMICS Publishing Group
Date: 2016
Publisher: Wiley
Date: 27-05-2023
DOI: 10.1111/EPI.17644
Abstract: Improved quality of life (QoL) is an important outcome goal following epilepsy surgery. This study aims to quantify change in QoL for adults with drug‐resistant epilepsy (DRE) who undergo epilepsy surgery, and to explore clinicodemographic factors associated with these changes. We conducted a systematic review and meta‐analysis using Medline, Embase, and Cochrane Central Register of Controlled Trials. All studies reporting pre‐ and post‐epilepsy surgery QoL scores in adults with DRE via validated instruments were included. Meta‐analysis assessed the postsurgery change in QoL. Meta‐regression assessed the effect of postoperative seizure outcomes on postoperative QoL as well as change in pre‐ and postoperative QoL scores. A total of 3774 titles and abstracts were reviewed, and ultimately 16 studies, comprising 1182 unique patients, were included. Quality of Life in Epilepsy Inventory–31 item (QOLIE‐31) meta‐analysis included six studies, and QOLIE‐89 meta‐analysis included four studies. Postoperative change in raw score was 20.5 for QOLIE‐31 (95% confidence interval [CI] = 10.9–30.1, I 2 = 95.5) and 12.1 for QOLIE‐89 (95% CI = 8.0–16.1, I 2 = 55.0%). This corresponds to clinically meaningful QOL improvements. Meta‐regression demonstrated a higher postoperative QOLIE‐31 score as well as change in pre‐ and postoperative QOLIE‐31 score among studies of cohorts with higher proportions of patients with favorable seizure outcomes. At an in idual study level, preoperative absence of mood disorders, better preoperative cognition, fewer trials of antiseizure medications before surgery, high levels of conscientiousness and openness to experience at the baseline, engagement in paid employment before and after surgery, and not being on antidepressants following surgery were associated with improved postoperative QoL. This study demonstrates the potential for epilepsy surgery to provide clinically meaningful improvements in QoL, as well as identifies clinicodemographic factors associated with this outcome. Limitations include substantial heterogeneity between in idual studies and high risk of bias.
Publisher: BMJ
Date: 24-05-2018
DOI: 10.1136/JNNP-2018-ANZAN.73
Abstract: Seizures are common in hospitals, both as presentations to Emergency Departments (ED) and as hospital onset seizures (HOS), occurring in ward patients hospitalised for non-seizure reasons. Prompt identification of seizure aetiology is important, as it affects prognosis and management choices. Acute symptomatic seizures due to acute disturbance of brain function have a far lower risk of recurrence compared to unprovoked seizures. Timely investigations and specialist review assesses in idual risk for seizure recurrence, which then guides therapeutic decisions including antiepileptic drug (AED) use. This study includes a larger proportion of older patients than usually reported, and as such, provides important insights into seizure aetiology and management strategies in this demographic. This retrospective survey of medical charts reviewed patients aged 18 or over with a hospital separation coded as ICD-10 G40 (Epilepsy), G41 (Status epilepticus), or R56.9 (convulsions not otherwise specified), presenting between 1 January 2008 through 30 November 2016, to a large metropolitan private hospital. 97 episodes of ED attendance for first seizure and 54 episodes of HOS were identified. Median age was 70 years in ED-cohort and 80.5 years in HOS-cohort. Symptomatic seizure risk factors were identified in 62.89% of ED-cohort and 83.33% of HOS-cohort, including exposure to known epileptogenic drugs in 38.89% of HOS-cohort. Antiepileptic drugs (AEDs) were prescribed on discharge to 74.23% of ED-cohort and 81.48% of HOS-cohort, but far fewer had scheduled Neurologist review (58.76% of ED- and 35.19% of HOS-cohorts). This study includes a larger proportion of older patients than usually reported, and as such, provides important insights into seizure aetiology and management strategies in this demographic. This includes caution when prescribing known epileptogenic drugs mindful prescription of AED on discharge and ensuring adequate Neurologist follow-up to monitor further seizure activity, addressing seizure risk factors, and ongoing need for AED.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 15-09-2020
DOI: 10.1212/WNL.0000000000010862
Abstract: To determine the health economic burden of epilepsy for Australians of working age by using life table modeling and to model whether improved seizure control may result in substantial health economic benefits. Life table modeling was used for working age Australians aged 15–69 years with epilepsy and the cohort was followed until age 70 years. Published 2017 population and epilepsy-related data regarding epilepsy prevalence, mortality, and productivity were used. This model was then re-simulated, assuming the cohort no longer had epilepsy. Differences in outcomes between these cohorts were attributed to epilepsy. Scenarios were also simulated in which the proportion of seizure-free patients increased from baseline 70% up to 75% and 80%. In 2017, Australians of working age with epilepsy followed until age 70 years were predicted to experience over 14,000 excess deaths, more than 78,000 years of life lost, and over 146,000 productivity-adjusted life years lost due to epilepsy. This resulted in lost gross domestic product (GDP) of US $22.1 billion. Increasing seizure freedom by 5% and 10% would reduce health care costs, save years of life, and translate to US $2.6 billion and US $5.3 billion GDP retained for seizure freedom rates of 75% and 80%, respectively. Our study highlights the considerable societal and economic burden of epilepsy. Relatively modest improvements in overall seizure control could bring substantial economic benefits.
Publisher: Wiley
Date: 06-06-2023
DOI: 10.1002/EPI4.12766
Abstract: Anxiety and depression are common comorbidities in people living with epilepsy. Emerging research suggests that these conditions may even predate epilepsy onset. This review aimed to summarize the prevalence of clinically significant anxiety and depressive symptoms in people with first seizures and newly diagnosed epilepsy, as well as clinicodemographic factors associated with these symptoms. A scoping literature review was performed. OVID Medline and Embase were searched from January 1, 2000, through May 1, 2022. Articles of interest were selected based on predetermined inclusion and exclusion criteria. From 1836 studies identified on screening, 16 met eligibility criteria and were included in the review. Clinically significant anxiety and depressive symptoms, as determined by validated cutoff scores for anxiety and depression screening instruments, were common in people with first seizures (range 13–28%) and newly diagnosed epilepsy (range 11–45%). They were associated with a range of clinicodemographic factors including past psychiatric history and trauma, personality traits, self‐esteem, and stigma profiles. There is substantial evidence that clinically significant anxiety and depressive symptoms are often present at the time and shortly following the first seizure or epilepsy diagnosis. Future research is needed to better understand the complex interactions between these common psychiatric comorbidities, new‐onset seizure disorders, and certain clinicodemographic characteristics. This knowledge may inform targeted and holistic treatment approaches.
Publisher: Elsevier BV
Date: 02-2018
DOI: 10.1016/J.JOCN.2018.10.084
Abstract: A previously well man presented with several months' history of neurological symptoms including diplopia and balance difficulties. Examination revealed fluctuating neurological deficits, fatigable weakness and slowed saccades. Extensive testing revealed mildly elevated cerebrospinal fluid protein, strongly positive single fiber electromyography and a dorsal pontine lesion at the floor of the 4th ventricle. An autoimmune process was felt to best account for the myasthenic presentation while the differential diagnoses for the brainstem lesion included glioma. Aggressive immunotherapy failed to halt clinical deterioration over months he developed generalized weakness, aspiration pneumonia and died. Post-mortem analysis revealed glioneuronal tumor infiltration throughout the brainstem, cerebellum and along the meningeal surface. This is an unusual case of an infiltrative brainstem lesion, with the presentation suggesting a primary diagnosis of myasthenia gravis. The progressive nature of the illness, despite aggressive immune therapy, together with slow saccades, underscored a more sinister process. Cerebral imaging should be performed in patients with fluctuating neurological symptoms, progressive deterioration, and ocular, bulbar, respiratory, or pyramidal pattern deficits, and differentials for contrast-enhancing brain lesions should include primary brain tumors. In such cases, biopsy must proceed if the disease is of relatively recent onset, to facilitate diagnosis and maximize treatment opportunities.
Publisher: Informa UK Limited
Date: 30-04-2023
Publisher: Wiley
Date: 22-08-2023
DOI: 10.1002/EPI4.12809
Abstract: To investigate the trends in antiseizure medications (ASMs) use following ischemic stroke and to examine factors associated with use of newer‐ and older‐generation ASMs. A retrospective cohort study was conducted using state‐wide linked health datasets. Patients who were hospitalized with a first‐ever ischemic stroke between 2013 and 2017 and were dispensed ASM within 12 months from discharge were included. Logistic regression was used to examine the predictors of receiving newer‐generation ASMs. Generalized linear modeling was used to identify factors associated with ASM use after ischemic stroke. Of 19 601 people hospitalized with a first‐ever ischemic stroke, 989 were dispensed an ASM within 12 months from discharge. The most prevalent first ASMs were levetiracetam (38.0%), valproate (25.8%), and carbamazepine (10.3%). Most people were dispensed ASM monotherapy (86.9%). There was a shift toward the use of newer‐generation ASMs between 2013 and 2017 (odds ratio [OR] 2.82, 95% confidence interval [CI] 1.92–4.16). Metropolitan residents were more likely to be dispensed newer‐generation ASMs as a first‐line treatment (OR 1.79, 95% CI 1.31–2.45). People over 85 years (OR 0.38, 95% CI 0.23–0.64), with dementia (OR 0.35, 95% CI 0.19–0.63) and psychotic comorbidities (OR 0.29, 95% CI 0.09–0.96) were less likely to be dispensed newer‐generation ASMs. Older age (coefficient [ β ] 0.23, P = 0.030), history of beta blocker use ( β 0.17, P = 0.029), multiple ASMs ( β 0.78, P 0.001), and newer‐generation ASM ( β 0.23, P = 0.001) were associated with higher defined daily dose (DDD) of ASM whereas female sex and being married were associated with lower DDD. There has been a shift toward newer‐generation ASMs for poststroke seizures and epilepsy. Concerningly, vulnerable patient groups were more likely to be dispensed older‐generation ASMs. This may lead to unnecessary exposure to adverse events and drug–drug interactions. Further research is needed to evaluate comparative effectiveness and safety of newer‐ and older‐generation ASMs in poststroke populations.
Publisher: Elsevier BV
Date: 06-2015
DOI: 10.1016/J.JOCN.2014.11.025
Abstract: This article discusses three patients with likely Hirayama disease. They have no other significant past medical history and no personal or family history of other neurological disorders. Hirayama disease is a form of cervical myelopathy attributed to forward displacement of the posterior cervical dural sac on neck flexion with resultant cord compression and/or venous congestion. It is characterized by a pure motor focal amyotrophy in the distribution of C7, C8 and T1 spinal segmental-innervated muscles and differs from other motor neuron diseases by virtue of its ultimately non-progressive course.
Publisher: BMJ
Date: 24-05-2018
DOI: 10.1136/JNNP-2018-ANZAN.106
Abstract: First seizure diagnosis may be delayed due to financial, geographical or social barriers to healthcare, or misdiagnosis with differentials including syncope or stroke. Seizures may recur until correct diagnosis and appropriate treatment is instituted meanwhile, patients may experience increased seizure-related morbidity and mortality. We compare patient and seizure characteristics between a first-ever ‘new-onset’ seizure (NOS) cohort, and a recurrent-untreated seizure (RUS) cohort. Medical charts were reviewed to extract information on patient demographics and clinical characteristics using a standardised proforma. Inclusion criteria were patients aged 18 or over who attended a tertiary-level Melbourne hospital between 1 January 2008 and 30 November 2016 with discharge codes ICD-10 G40-Epilepsy, G41-Status epilepticus, or R56.9-Unspecified convulsions. 367 episodes were identified. 151 episodes met inclusion criteria: new-onset seizures (115) and recurrent-untreated seizures. 36 216 excluded cases included pre-existing epilepsy (186), and non-seizure events. 30 RUS-cohort experienced a median of two seizures prior to coming to medical attention, most commonly focal impaired awareness seizures (50.00%). Considering the index seizure, focal seizures were more common in RUS-cohort (36.11 vs 24.35%) while primary generalised seizures predominated in NOS-cohort (62.61% vs 50.00%). Compared to NOS-cohort, RUS-cohort was more likely to have unprovoked seizures (72.22% vs 55.65%), identifiable remote risk factors (41.67% vs 26.09%), younger age (69 vs 76), normal MRI and EEG, and be discharged on antiepileptic drugs (86.11% vs 73.91%). RUS-cohort was more likely to receive Neurology outpatient follow-up (72.22% vs 39.99%), and in a more timely manner compared to NOS-cohort (30.56% vs 11.31% saw a Neurologist within a month of discharge). Recurrent-untreated seizures often have subtler semiology and are more likely to have normal MRI and EEG results than patients presenting immediately following new-onset seizures. RUS-cohort tend to receive more inpatient investigations and AED prescriptions, and are offered more timely neurology follow-up than NOS-cohort.
Publisher: BMJ
Date: 24-05-2018
DOI: 10.1136/JNNP-2018-ANZAN.87
Abstract: A 64 year old woman presented with livedo reticularis and peripheral neuropathy secondary to Type 1 (IgM paraproteinemia) cryoglobulinemia, associated with lymphoplasmacytic lymphoma. Type 1 cryoglobulinemia is rare and remains poorly studied. However, given the common association of Type 1 cryoglobulinemia with lymphoproliferative diseases, it is important to consider Type 1 cryoglobulinemia as a differential diagnosis in presentations of a rash and peripheral neuropathy, and search for underlying malignancy. Our patient presented with a leukocytoclastic vasculitic rash over bilateral lower limbs, which improved with topical betamethasone and oral prednisolone. Two months later, she had rapidly progressive right upper limb and bilateral lower limb weakness, absent reflexes in these limbs, and right arm reduced sensation. Nerve conduction studies revealed generalised axonal sensorimotor peripheral neuropathy in all four limbs, most prominent in the right upper limb. She then developed a livedo reticularis rash over her right forearm and punch biopsy revealed luminal pseudo-thrombi in small vessels consistent with Type 1 cryoglobulinemia. Her cryoglobulin (1558 mg/L, N 0–50 mg/L) and IgM paraprotein levels (4 g/L, N 0.4–2.3) were elevated. Vasculitic and other infective screens were unremarkable. Computer tomography imaging of chest, abdomen and pelvis found widespread lymphadenopathy. Subsequent lymph node core biopsy and bone marrow aspirate revealed lymphoplasmacytic lymphoma—the likely underlying cause of the Type 1 (IgM paraproteinemia) cryoglobulinemia. Peripheral neuropathy is commonly associated with Type 2 and 3 cryoglobulinemia, especially in the presence of hepatitis C infection. However, reports of vasculitic peripheral neuropathy due to Type 1 cryoglobulinemia are limited. Early recognition is essential to allow the identification and treatment of the underlying haematological malignancy, commonly associated with Type 1 cryoglobulinemia. Treatment of the underlying cause indirectly treats the cryoglobulinemia, and avoids or reduces the associated sometimes severe cutaneous, neurological, and renal manifestations of this condition.
Publisher: Wiley
Date: 18-03-2021
DOI: 10.1111/EPI.16871
Abstract: This study was undertaken to identify factors that predict discordance between the screening instruments Neurological Disorders Depression Inventory for Epilepsy (NDDI‐E) and Generalized Anxiety Disorder scale (GAD‐7), and diagnoses made by qualified psychiatrists among patients with seizure disorders. Importantly, this is not a validation study rather, it investigates clinicodemographic predictors of discordance between screening tests and psychiatric assessment. Adult patients admitted for inpatient video‐electroencephalographic monitoring completed eight psychometric instruments, including the NDDI‐E and GAD‐7, and psychiatric assessment. Patients were grouped according to agreement between the screening instrument and psychiatrists’ diagnoses. Screening was "discordant" if the outcome differed from the psychiatrist's diagnosis, including both false positive and false negative results. Bayesian statistical analyses were used to identify factors associated with discordance. A total of 411 patients met inclusion criteria mean age was 39.6 years, and 55.5% ( n = 228) were female. Depression screening was discordant in 33% of cases ( n = 136/411), driven by false positives ( n = 76/136, 56%) rather than false negatives ( n = 60/136, 44%). Likewise, anxiety screening was discordant in one third of cases ( n = 121/411, 29%) due to false positives ( n = 60/121, 50%) and false negatives ( n = 61/121, 50%). Seven clinical factors were predictive of discordant screening for both depression and anxiety: greater dissociative symptoms, greater patient‐reported adverse events, subjective cognitive impairment, negative affect, detachment, disinhibition, and psychoticism. When the analyses were restricted to only patients with psychogenic nonepileptic seizures (PNES) or epilepsy, the rate of discordant depression screening was higher in the PNES group ( n = 29, 47%) compared to the epilepsy group ( n = 70, 30%, Bayes factor for the alternative hypothesis = 4.65). Patients with seizure disorders who self‐report a variety of psychiatric and other symptoms should be evaluated more thoroughly for depression and anxiety, regardless of screening test results, especially if they have PNES and not epilepsy. Clinical assessment by a qualified psychiatrist remains essential in diagnosing depressive and anxiety disorders among such patients.
Publisher: Wiley
Date: 30-11-2019
DOI: 10.1111/EPI.16396
Abstract: Epilepsy is common and carries substantial morbidity, and therefore identifying cost-effective health interventions is essential. Cost-utility analysis is a widely used method for such analyses. For this, health conditions are rated in terms of utilities, which provide a standardized score to reflect quality of life. Utilities are obtained either indirectly using quality of life questionnaires, or directly from patients or the general population. We sought to describe instruments used to estimate utilities in epilepsy populations, and how results differ according to methods used. We undertook a systematic review of studies comparing at least two instruments for obtaining utilities in epilepsy populations. MEDLINE, Embase, ScienceDirect, Cochrane Library, Google Scholar, and gray literature were searched from inception to June 2019. Mean utilities were recorded and compared for each method. Of the 38 unique records initially identified, eight studies met inclusion criteria. Utilities were highest for direct "tradeoff" methods, obtained via instruments including standard gamble (0.93) and time tradeoff (0.92), compared to indirect methods, obtained via instruments including EuroQoL five-dimensional form (range = 0.72-0.86) and Health Utilities Index Mark 3 (range = 0.52-0.71). Visual analog scale (VAS), a direct "nontradeoff" instrument, provided equal or lower utilities (range = 68.0-79.8) compared to indirect instruments. Direct methods, with the important exception of VAS, may provide higher utilities than indirect methods. More studies are needed to identify the most appropriate utility instruments for epilepsy populations, and to investigate whether there is variation between utilities for different types of epilepsy and other patient- and disease-specific factors.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 26-09-2018
DOI: 10.1212/CPJ.0000000000000524
Abstract: New-onset seizures are frequently encountered in community and hospital settings. It is likely that seizures presenting in these distinct settings have different etiologies and prognoses, requiring different investigation and treatment approaches. We directly compare the presentation and management of patients with community- and hospital-onset first seizures attending the same hospital. We reviewed the medical records of patients aged 18 years or older with discharge International Classification of Diseases, Australian Classification ( ICD-10-AM ) codes of G40 (epilepsy), G41 (status epilepticus), and R56.8 (unspecified convulsions), who attended a general hospital in Melbourne, Australia, from January 1, 2008, through November 30, 2016. Patients with new-onset seizures were included for analysis. A total of 367 patients were discharged with a relevant ICD-10-AM code. Among them, 151 patients met the inclusion criteria: 97 presented to the emergency department with community-onset seizure (median age 70 years), and 54 experienced seizures during hospitalization for other indications (median age 80.5 years). Provoked seizures were more common in the latter group (26.8% vs 63.0%, p 0.001), with exposure to proconvulsant drugs a major risk factor. Despite not fulfilling the International League Against Epilepsy (ILAE) diagnostic criteria, 72.5% (58/80) who survived to discharge were prescribed antiepileptic drug (AED) therapy, whereas 19.0% (12/63) of those who met the ILAE criteria were not. Hospitalized elderly patients are at an increased risk of provoked seizures, and caution should be exercised when prescribing potential proconvulsant medications and procedures. A more standardized approach to AED prescribing is needed. Further studies should consider morbidity, mortality, and health economic effects of first seizures and assess optimal management to improve outcomes in this cohort.
Publisher: Oxford University Press (OUP)
Date: 25-10-2021
Abstract: People with epilepsy have variable and dynamic trajectories in response to antiseizure medications. Accurately modelling long-term treatment response will aid prognostication at the in idual level and health resource planning at the societal level. Unfortunately, a robust model is lacking. We aimed to develop a Markov model to predict the probability of future seizure-freedom based on current seizure state and number of antiseizure medication regimens trialled. We included 1795 people with newly diagnosed epilepsy who attended a specialist clinic in Glasgow, Scotland, between July 1982 and October 2012. They were followed up until October 2014 or death. We developed a simple Markov model, based on current seizure state only, and a more detailed model, based on both current seizure state and number of antiseizure medication regimens trialled. Sensitivity analyses were performed for the regimen-based states model to examine the effect of regimen changes due to adverse effects. The model was externally validated in a separate cohort of 455 newly diagnosis epilepsy patients seen in Perth, Australia, between May 1999 and May 2016. Our models suggested that once seizure-freedom was achieved, it was likely to persist, regardless of the number of antiseizure medications trialled to reach that point. The likelihood of achieving long-term seizure-freedom was highest with the first antiseizure medication regimen, at approximately 50%. The chance of achieving seizure-freedom fell with subsequent regimens. Fluctuations between seizure-free and not seizure-free states were highest earlier on but decreased with chronicity of epilepsy. Seizure-freedom/recurrence risk tables were constructed with these probability data, similar to cardiovascular risk tables. Sensitivity analyses showed that the general trends and conclusions from the base model were maintained despite perturbing the model and input data with regimen changes due to adverse effects. Quantitative comparison with the external validation cohort showed excellent consistency at Year 1, good at Year 3 and moderate at Year 5. Quantitative models, as used in this study, can provide pertinent clinical insights that are not apparent from simple statistical analysis alone. Attaining seizure freedom at any time in a patient’s epilepsy journey will confer durable benefit. Seizure-freedom risk tables may be used to in idualize the prediction of future seizure control trajectory.
Publisher: Wiley
Date: 20-12-2021
DOI: 10.1002/EPI4.12571
Abstract: New‐onset seizures affect up to 10% of people over their lifetime, however, their health economic impact has not been well‐studied. This prospective multicenter study will collect patient‐reported outcome measures (PROMs) from adults with new‐onset seizures seen in six Seizure Clinics across Melbourne, Australia and The University of Colorado, USA. Approximately 450 eligible patients will be enrolled in the study at or following their initial attendance to Seizure Clinics at the study hospitals. Inclusion criteria for the study group are those with new‐onset acute symptomatic seizures, new‐onset unprovoked seizures, and new‐onset epilepsy. Inclusion criteria for the three comparator groups are those with noncardiac syncope, those with psychogenic nonepileptic seizures, as well as published PROMs data from the Australian general population. Exclusion criteria are those aged less than 18 years, those with a preexisting epilepsy diagnosis, and those with intellectual disabilities or other impairments which would preclude them from comprehending and completing the questionnaires. Patients will complete eight online questionnaires regarding the effect that their seizures (or seizure mimics) have had on various aspects of their life. These questionnaires will be readministered at 6 and 12 months. Patients with new‐diagnosis epilepsy will also be asked to share the reasons why they have accepted or declined antiseizure medications. Primary outcome measures will be quality of life, work productivity, informal care needs, and mood, at baseline compared to 6 and 12 months later for those with new‐onset seizures and comparing these outcomes to those in the three comparator groups. Secondary outcomes include mapping of QoLIE‐31 to the EQ‐5D‐5L in epilepsy, modelling indirect costs of new‐onset seizures, and exploring why patients may or may not wish to take antiseizure medications. These data will form an evidence‐base for future studies that examine the effectiveness of various healthcare interventions for new‐onset seizure patients. This study is approved by the Alfred Health Human Research Ethics Committee (SERP: 52 538, Alfred HREC: 307/19), the Austin Health Human Research Ethics Committee (HREC/59148/Austin‐2019), and the Colorado Multiple Institutional Review Board (COMIRB) (COMIRB #20‐3028). ACTRN12621000908831.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-12-2020
Publisher: S. Karger AG
Date: 2013
DOI: 10.1159/000348310
Abstract: b i Background: /i /b It has been described that lacunar infarct is characterized by its smallish size (15-20 mm) in the axial plane. However, the size of the basal ganglia artery responsible for this type of infarct is uncertain. Detection of small arterial occlusion is not possible with current angiography, hindering correlation of arterial occlusion with subcortical infarct size. Recently, investigators have published microangiographic templates of arteries supplying the basal ganglia. These templates display first-order (proximal) to third-order (distal) branching of these arteries and can help with estimating the likely site of arterial disease in subcortical infarcts. We correlated the dimensions of subcortical infarcts with the order of arterial branching described in a microangiographic template. Such data may provide further clues about the type of arteries associated with subcortical infarcts and assist in refining the concept of lacunar infarction. b i Method: /i /b Patients with subcortical infarcts on MR imaging (MRI) admitted to our institution between 2009 and 2011 were included in the study. Infarcts were manually segmented and registered to a standard brain template. These segmented infarcts were scaled and overlapped with published microangiographic templates, and used by 6 raters who independently estimated the branching order of arterial disease that might result in these infarcts. We used regression analysis to relate these ratings to infarct dimensions. b i Results: /i /b Among 777 patients, there were 33 (58% male) patients with subcortical infarcts. The mean age was 63.1 ± 15.1 years. Infarct dimensions for the groups were as follows: group 1 (first-order branch): height 37.6 ± 7.4 mm, horizontal width 21.2 ± 11.6 mm, anterior-posterior length 36.8 ± 20.1 mm group 2 (second-order branch): height 25.2 ± 7.9 mm, horizontal width 16.6 ± 22.8 mm, anterior-posterior length 16.1 ± 8.0 mm group 3 (third-order branch): height 11.6 ± 5.7 mm, axial width 5.3 ± 3.1 mm, anterior-posterior length 5.5 ± 3.8 mm. Increasing vessel branching order (from large to small vessels) was linearly and negatively associated with infarct height (β = -16.7 mm per change in branching order disease, 95% CI -20.3, -13.1 mm, p 0.01) and anterior-posterior length (β = -16.8 mm per change in branching order disease, 95% CI -23.2, -10.5 mm, p 0.01). b i Discussion: /i /b Based on MRI infarct dimensions and a microangiographic template, it may be possible to estimate the branching order of the artery involved in subcortical infarcts. Further, our small data set suggests that reliance on an axial dimension of 15-20 mm may not be the best approach to classifying lacunar infarct. This finding needs to be confirmed in a larger data set.
Publisher: Wiley
Date: 19-07-2023
DOI: 10.1002/EPI4.12795
Abstract: To determine predictors of successful ictal Single Photon Emission Computed Tomography (SPECT) injections during Epilepsy Monitoring Unit (EMU) admissions for patients undergoing presurgical evaluation for drug resistant focal epilepsy. In this retrospective study, consecutive EMU admissions were analysed at a single centre between 2019‐2021. All seizures that occurred during the admission were reviewed. ‘Injectable seizures’ occurred during hours when the radiotracer was available. EMU‐level data were analysed to identify factors predictive of an EMU admission with a successful SPECT injection (successful admission). Seizure‐level data were analysed to identify factors predictive of an ‘injectable seizure’ receiving a SPECT injection during the ictal phase (successful injection). A multivariate generalised linear model was used to identify predictive variables. 125 EMU admissions involving 103 patients (median 37 years, IQR27.0‐45.5) were analysed. 38.8% of seizures that were eligible for SPECT (n=134) were successfully injected this represented 17.4% of all seizures (n=298) that occurred during admission. Unsuccessful admissions were most commonly due to a lack of seizures during EMU‐SPECT (19.3%) or no 'injectable seizures’ (62.3%). Successful EMU‐SPECT was associated with baseline seizure frequency per week (95%CI 2.1‐3.0, p .001) and focal PET hypometabolism (95%CI 2.0‐3.7, p .001). On multivariate analysis, the only factor associated with successful injection was patients being able to indicate they were having a seizure to staff (95%CI 1.0‐4.4, p=0.038). Completing a successful ictal SPECT study remains challenging. Baseline seizure frequency of per‐week, a PET hypometabolic focus and a patient's ability to indicate seizure onset were identified as predictors of success. These findings may assist EMUs in optimising their SPECT protocols, patient selection, and resource allocation.
No related grants have been discovered for Emma Foster.