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Angus-Leppan H, Arkell R, Watkins L, Heaney D, Cooper P, Shankar R. New valproate regulations, informed choice and seizure risk. J Neurol 2024; 271:5671-5686. [PMID: 38896265 PMCID: PMC11319429 DOI: 10.1007/s00415-024-12436-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 06/21/2024]
Abstract
Valproate is the most effective medication for generalised epilepsies, and several specific epilepsy syndromes. For some people, it will be the only medication to establish seizure remission, and withdrawing it carries risks of seizure recurrence and Sudden Unexpected Death in Epilepsy (SUDEP). It is also of proven efficacy for bipolar disorder and migraine prevention. Guidelines based on observational and epidemiological studies stress that maternal valproate related teratogenicity and neurodevelopmental effects are significantly higher than for other antiseizure medications (ASMs). It should, therefore, only be used if other medications are ineffective and after balancing the teratogenicity risk. Regulatory restrictions have changed prescribing practices and reduced valproate use. The number of other medications that must be trialled in the different conditions for which valproate has effectiveness and the consequences of the lack of efficacy of those drugs leading to significant harm including death remains unexplored. Risk minimisation measures (RMMs) for valproate, chiefly Pregnancy Prevention practices (PPP), consider foetal risk and not risk to people living with epilepsy. In the United Kingdom (UK), limitations relating to valproate use in all people < 55 years commenced in January 2024. While the evidence in child-bearing women is not disputed, the data in males are based on animal models, case reports, and one commissioned, unpublished, non-peer reviewed report unavailable to the UK public, stakeholder charities or professionals. Evidence suggests that 30-40% of people switching from valproate have breakthrough seizures. Thus, an estimated 21,000-28000 people in the UK will imminently be exposed to the potential hazards of breakthrough seizures, including death. There is little government investment in monitoring the effects of these changes to valproate prescribing on patient health and quality of life. This review summarises the history of valproate regulation, evidence underpinning it and argues how the latest regulations in the UK do not align with the country's medical regulatory bodies ethical principles nor with the Montgomery principles of informed patient choice and autonomy. It dissects how such regulations infringe Common Law principles, nor give due regard for patient outcomes beyond reproduction. The paper looks to provide recommendations to redress these concerns while appreciating the core need for such governance to emerge in the first place.
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Affiliation(s)
- Heather Angus-Leppan
- University of East London, Stratford, E15 4LZ, UK.
- National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, Queen Square, London, WC1N 3BG, UK.
- Royal Free London, Pond Street, London, NW3 2QG, UK.
| | - Rachel Arkell
- University of East London, Stratford, E15 4LZ, UK
- Kent Law School, University of Kent, Canterbury, CT2 7NS, UK
- Centre for Reproductive Research and Communication, British Pregnancy Advisory Service (BPAS), London, UK
| | - Lance Watkins
- University of South Wales, Pontypridd, UK
- University of Plymouth, Plymouth, UK
| | - Dominic Heaney
- National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, Queen Square, London, WC1N 3BG, UK
| | - Paul Cooper
- University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Greater Manchester, Salford Royal Hospital, Stott Lane, Salford, M6 8HD, UK
| | - Rohit Shankar
- Peninsula School of Medicine, University of Plymouth, Drake Circus, Plymouth, PL4 8AA, UK
- University of Plymouth, Plymouth, UK
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Badger S, Watkins LV, Bassett P, Roy A, Eyeoyibo M, Sawhney I, Purandare K, Wood L, Pugh A, Hammett J, Sheehan R, Tromans S, Shankar R. The relationship between clinical presentation and the nature of care in adults with intellectual disability and epilepsy - national comparative cohort study. BJPsych Open 2024; 10:e94. [PMID: 38686441 PMCID: PMC11060072 DOI: 10.1192/bjo.2024.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND A quarter of People with Intellectual Disabilities (PwID) have epilepsy compared with 1% of the general population. Epilepsy in PwID is a bellwether for premature mortality, multimorbidity and polypharmacy. This group depends on their care provider to give relevant information for management, especially epilepsy. There is no research on care status relationship and clinical characteristics of PwID and epilepsy. AIM Explore and compare the clinical characteristics of PwID with epilepsy across different care settings. METHOD A retrospective multicentre cohort study across England and Wales collected information on seizure characteristics, intellectual disability severity, neurodevelopmental/biological/psychiatric comorbidities, medication including psychotropics/anti-seizure medication, and care status. Clinical characteristics were compared across different care settings, and those aged over and younger than 40 years. RESULTS Of 618 adult PwID across six centres (male:female = 61%:39%), 338 (55%) received professional care whereas 258 (42%) lived with family. Significant differences between the care groups existed in intellectual disability severity (P = 0.01), autism presence (P < 0.001), challenging behaviour (P < 0.001) and comorbid physical conditions (P = 0.008). The two groups did not vary in intellectual disability severity/genetic conditions/seizure type and frequency/psychiatric disorders. The professional care cohort experienced increased polypharmacy (P < 0.001) and antipsychotic/psychotropic use (P < 0.001/P = 0.008).The over-40s cohort had lower autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) comorbidity (P < 0.001/P = 0.007), increased psychiatric comorbidity and challenging behaviour (P < 0.05), physical multimorbidity (P < 0.001), polypharmacy (P < 0.001) and antipsychotic use (P < 0.001) but reduced numbers of seizures (P = 0.007). CONCLUSION PwID and epilepsy over 40 years in professional care have more complex clinical characteristics, increased polypharmacy and antipsychotic prescribing but fewer seizures.
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Affiliation(s)
- Sarah Badger
- Cornwall Partnership NHS Foundation Trust, Truro, UK
| | - Lance V Watkins
- University of South Wales, Pontypridd, UK; Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK; and Swansea Bay University Health Board, Port Talbot, UK
| | | | - Ashok Roy
- Coventry and Warwickshire Partnership NHS Trust, Coventry, UK
| | | | - Indermeet Sawhney
- Hertfordshire Partnership University NHS Foundation Trust, St Albans, UK
| | - Kiran Purandare
- Central and Northwest London NHS Foundation Trust, London, UK
| | - Laurie Wood
- Swansea Bay University Health Board, Port Talbot, UK
| | - Andrea Pugh
- Swansea Bay University Health Board, Port Talbot, UK
| | | | - Rory Sheehan
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Samuel Tromans
- SAPPHIRE Group, Department of Population Health Sciences, University of Leicester, Leicester, UK; and Adult Learning Disability Service, Leicestershire Partnership NHS Trust, Leicester, UK
| | - Rohit Shankar
- Cornwall Partnership NHS Foundation Trust, Truro, UK; and Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK
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Casey E, Linehan C. The physician's role in reducing health disparities for persons with epilepsy and intellectual disability: "it's not just epilepsy…you really have to take a deeper dive.". Epilepsy Behav 2024; 151:109646. [PMID: 38271851 DOI: 10.1016/j.yebeh.2024.109646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/02/2024] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
Epilepsy affects approximately 25 % of people with intellectual disability (ID). Despite this high prevalence, evidence of health disparity exists in healthcare access and health outcomes for this population. Patients with ID experience additional challenges in accessing appropriate epilepsy care, and are at greater risk of experiencing inappropriate prescribing, polypharmacy and misdiagnosis compared with the general population. The expectations, attitudes and actions of physicians are key in addressing health inequalities, particularly those which disproportionately impact a specific group of patients, such as patients with ID and epilepsy. This qualitative study aimed to explore the views of specialist physicians as to why they believe this patient group are at a disadvantage when it comes to accessing appropriate epilepsy care, and how physicians can intervene to ensure that patients with ID are given equal access to suitable epilepsy care, and equal opportunity to achieve the best possible treatment outcomes. Semi-structured interviews were carried out with six physicians, located in six countries, who specialise in the care of persons with ID who have epilepsy. Interviews sought views on prognostic expectations, experiences of disparities in epilepsy care, and suggestions for advocacy interventions. Interviews were analysed using reflexive thematic analysis. Three core themes and nine subthemes were identified. Core themes included (1) 'Nervousness in care and treatment,' which reflected participants' descriptions of a nervousness by colleagues when treating epilepsy in patients with ID. (2) 'Taking a deeper dive' captured the harmful effects of accepting "common dogma," as well as the issue of a lack of clarity around treatment pathways for patients with epilepsy and ID. (3) 'Teach me' illustrated the importance of shared expertise, reflective practice and continued research and advocacy. Findings reflected participants' recommendations to address disparities in epilepsy care for patients with ID. These recommendations highlighted education and training, taking time to learn how to communicate in different ways, and regular reflection on personal assumptions and biases as important contributors to addressing inequalities in epilepsy care for patients with ID. It is hoped that findings will prompt those providing epilepsy care to reflect on their own practice and identify ways in which they might intervene to minimise inadvertent harm and reduce health disparities in epilepsy care for patients with ID.
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Affiliation(s)
- Emma Casey
- University College Dublin, UCD School of Psychology, Dublin, Ireland.
| | - Christine Linehan
- University College Dublin, UCD School of Psychology, Dublin, Ireland; UCD Centre for Disability Studies, University College Dublin, Dublin, Ireland
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Watkins LV, Dunstall H, Musicha C, Lawthom C, John K, Bright C, Richings C, Harding K, Moon S, Pape SE, Winterhalder R, Allgar V, Thomas RH, McLean B, Laugharne R, Shankar R. Rapid switching from levetiracetam to brivaracetam in pharmaco-resistant epilepsy in people with and without intellectual disabilities: a naturalistic case control study. J Neurol 2023; 270:5889-5902. [PMID: 37610448 DOI: 10.1007/s00415-023-11959-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Approximately one quarter of people with an intellectual disability (PwID) have epilepsy of whom nearly three-quarters are pharmaco-resistant. There are higher reported neuropsychiatric side-effects to anti-seizure medication (ASM) in this group. Levetiracetam (LEV) is a first-line ASM with a stronger association with neuropsychiatric symptoms for PwID than other ASMs. Brivaracetam (BRV) is a newer ASM. Recent studies suggest a beneficial effect of swapping people who experience neuropsychiatric events with LEV to BRV. However, there is limited evidence of this for PwID. This evaluation analyses real world outcomes of LEV to BRV swap for PwID compared to those without ID. METHODS We performed a multicentre, retrospective review of clinical records. Demographic, clinical characteristics and reported adverse events of patients switched from LEV to BRV (2016-2020) were recorded at 3 months pre and 6- and 12-month post-BRV initiation. Outcomes were compared between PwID and those without and summarised using cross-tabulations and logistic regression models. A Bonferroni correction was applied. RESULTS Of 77 participants, 46 had ID and 52% had a past psychiatric illness. 71% participants switched overnight from LEV to BRV. Seizure reduction of > 50% was seen in 40% patients. Psychiatric illness history was predictive of having neuropsychiatric side-effects with LEV but not BRV (p = 0.001). There was no significant difference for any primary outcomes between PwID versus without ID. CONCLUSIONS Switching from LEV to BRV appears as well tolerated and efficacious in PwID as those without ID with over 90% still on BRV after 12 months.
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Affiliation(s)
- L V Watkins
- Swansea Bay University Health Board, Port Talbot, UK
- University of South Wales, Aberdare, UK
- University of Plymouth, Plymouth, UK
| | - H Dunstall
- Swansea Bay University Health Board, Port Talbot, UK
| | - C Musicha
- University of Plymouth, Plymouth, UK
| | - C Lawthom
- Aneurin Bevan University Health Board, Newport, UK
- Swansea University, Swansea, UK
| | - K John
- Aneurin Bevan University Health Board, Newport, UK
| | - C Bright
- University of South Wales, Aberdare, UK
- Aneurin Bevan University Health Board, Newport, UK
| | - C Richings
- Aneurin Bevan University Health Board, Newport, UK
| | - K Harding
- Aneurin Bevan University Health Board, Newport, UK
| | - S Moon
- Swansea Bay University Health Board, Port Talbot, UK
| | - S E Pape
- Oxleas NHS Foundation Trust, Kent, UK
| | | | - V Allgar
- University of Plymouth, Plymouth, UK
| | - R H Thomas
- Newcastle University, Newcastle upon Tyne, UK
- The Newcastle Upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, UK
| | - B McLean
- University of Plymouth, Plymouth, UK
| | | | - Rohit Shankar
- University of Plymouth, Plymouth, UK.
- Cornwall Partnership NHS Foundation Trust, Threemilestone Industrial Estate, Truro, TR4 9LD, UK.
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Yang W, Li MH, Yu JJ, Wong SHS, Sum RKW, Sit CHP. The Associations Between Accelerometer-Measured Physical Activity Levels and Mental Health in Children and Adolescents with Intellectual Disabilities During the COVID-19 Pandemic. J Autism Dev Disord 2023; 53:4809-4821. [PMID: 36181649 PMCID: PMC9526382 DOI: 10.1007/s10803-022-05777-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 12/05/2022]
Abstract
To examine the associations between physical activity (PA) levels and mental health in children and adolescents with intellectual disabilities (IDs) during the COVID-19 pandemic, 117 participants aged between 6 and 17 years with IDs from 10 Hong Kong special schools were included. There were positive dose-response associations between PA (i.e., light PA, moderate PA, and vigorous PA) and mental health, and participants with higher levels of moderate-to-vigorous PA (MVPA) and self-concept (SC) had better social quality of life (QoL) than those with lower levels of MVPA and SC. Moreover, personal and environmental factors such as age, body mass index, school, sex, ID level, and parental education level influenced the PA levels and QoL in children and adolescents with IDs.
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Affiliation(s)
- Wen Yang
- Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ming Hui Li
- Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jane Jie Yu
- Department of Sport and Exercise Science, Zhejiang University, Hangzhou, China
| | - Stephen Heung-Sang Wong
- Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Raymond Kim-Wai Sum
- Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Cindy Hui-Ping Sit
- Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong SAR, China.
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6
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Kim JY, Shin J, Kim L, Kim SH. Electroencephalography characteristics related to risk of sudden unexpected death in epilepsy in patients with Dravet syndrome. Front Neurol 2023; 14:1222721. [PMID: 37745659 PMCID: PMC10512954 DOI: 10.3389/fneur.2023.1222721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Objective To investigate the quantitative electroencephalography (EEG) features associated with a high risk of sudden unexpected death in epilepsy (SUDEP) in patients with Dravet syndrome (DS). Methods Patients with DS and healthy controls (HCs) who underwent EEG were included in the study. EEG signals were recorded using a 21 channel digital EEG system, and pre-processed data were analyzed to identify quantitative EEG features associated with a high SUDEP risk. To assess the risk of SUDEP, SUDEP-7 scores were used. Results A total of 64 patients with DS [38 males and 26 females, aged: 128.51 ± 75.50 months (range: 23-380 months)], and 13 HCs [7 males and 6 females, aged: 95.46 ± 86.48 months (range: 13-263 months)] were included. For the absolute band power, the theta power was significantly higher in the high-SUDEP group than in the low-SUDEP group in the central brain region. For the relative band power, the theta power was also significantly higher in the high-SUDEP group than in the low-SUDEP group in the central and occipital brain regions. The alpha power was significantly lower in the high-SUDEP group than in the low-SUDEP group in the central and parietal brain regions. Conclusion Patients with high SUDEP-7 scores have different EEG features from those with low SUDEP-7 scores, suggesting that EEG may be used as a biomarker of SUDEP in DS. Significance Early intervention in patients with DS at a high risk of SUDEP can reduce mortality and morbidity. Patients with high theta band powers warrant high-level supervision.
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Affiliation(s)
- Jeong-Youn Kim
- Electronics and Telecommunication Research Institute (ETRI), Daejeon, Republic of Korea
| | - Jeongyoon Shin
- School of Electrical and Electronic Engineering, College of Engineering, Yonsei University, Seoul, Republic of Korea
- Yonsei Biomedical Research Institute, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Laehyun Kim
- Center for Bionics, Korea Institute of Science and Technology, Seoul, Republic of Korea
- Department of HY-KIST Bio-Convergence, Hanyang University, Seoul, Republic of Korea
| | - Se Hee Kim
- Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Milne-Ives M, Duun-Henriksen J, Blaabjerg L, Mclean B, Shankar R, Meinert E. At home EEG monitoring technologies for people with epilepsy and intellectual disabilities: A scoping review. Seizure 2023; 110:11-20. [PMID: 37295277 DOI: 10.1016/j.seizure.2023.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/06/2023] [Accepted: 05/07/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Conducting electroencephalography in people with intellectual disabilities (PwID) can be challenging, but the high proportion of PwID who experience seizures make it an essential part of their care. To reduce hospital-based monitoring, interventions are being developed to enable high-quality EEG data to be collected at home. This scoping review aims to summarise the current state of remote EEG monitoring research, potential benefits and limitations of the interventions, and inclusion of PwID in this research. METHODS The review was structured using the PRISMA extension for Scoping Reviews and the PICOS framework. Studies that evaluated a remote EEG monitoring intervention in adults with epilepsy were retrieved from the PubMed, MEDLINE, Embase, CINAHL, Web of Science, and ClinicalTrials.gov databases. A descriptive analysis provided an overview of the study and intervention characteristics, key results, strengths, and limitations. RESULTS 34,127 studies were retrieved and 23 were included. Five types of remote EEG monitoring were identified. Common benefits included producing useful results of comparable quality to inpatient monitoring and patient experience. A common limitation was the challenge of capturing all seizures with a small number of localised electrodes. No randomised controlled trials were included, few studies reported sensitivity and specificity, and only three considered PwID. CONCLUSIONS Overall, the studies demonstrated the feasibility of remote EEG interventions for out-of-hospital monitoring and their potential to improve data collection and quality of care for patients. Further research is needed on the effectiveness, benefits, and limitations of remote EEG monitoring compared to in-patient monitoring, especially for PwID.
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Affiliation(s)
- Madison Milne-Ives
- Centre for Health Technology, University of Plymouth, Plymouth, PL4 6DT, UK
| | | | | | - Brendan Mclean
- Royal Cornwall Hospitals NHS Trust, Treliske, Truro, Cornwall, TR1 3LJ, UK; Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, PL4 8AA, UK; Cornwall Partnership NHS Foundation Trust, Carew House, Beacon Technology Park, Dunmere Rd, Bodmin, PL31 2QN, UK
| | - Rohit Shankar
- Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, PL4 8AA, UK; Cornwall Partnership NHS Foundation Trust, Carew House, Beacon Technology Park, Dunmere Rd, Bodmin, PL31 2QN, UK
| | - Edward Meinert
- Centre for Health Technology, University of Plymouth, Plymouth, PL4 6DT, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK; Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, W6 8RP, UK.
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Branford D, Sun JJ, Burrows L, Shankar R. Patterns of antiseizure medications prescribing in people with intellectual disability and epilepsy: A narrative review and analysis. Br J Clin Pharmacol 2023; 89:2028-2038. [PMID: 37060156 DOI: 10.1111/bcp.15748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/26/2023] [Accepted: 04/03/2023] [Indexed: 04/16/2023] Open
Abstract
People with intellectual disabilities (PwID) have a bidirectional relationship with epilepsy. Nearly 25% of PwID have seizures and 30% people with epilepsy are thought to have a significant intellectual impairment. Furthermore, 70% of PwID are thought to have treatment-resistant epilepsy. In the United Kingdom, antiseizure medications (ASMs) are the second most widely prescribed psychotropic agent for PwID. However, it is unclear what the current evidence and patterns is on current prescribing of ASMs, including when and how a case is made to withdraw them. A narrative review along with an analysis of large-scale NHS Digital published data (2015-2020) on several aspects of ASM prescribing by general practices for PwID was undertaken. The review results and data analysis are consolidated and presented as 11 themes to provide a comprehensive overview of the study topic. Recent studies estimate that one-third and one-fifth of PwID are prescribed ASMs. A history of epilepsy is seen as the primary prescribing reason; however, often it is a legacy, and the indication is no longer clear. The proportion receiving ASMs continues to rise with age. This pattern of use does not correlate well with seizure onset. There are limited data on de-prescribing ASMs in PwID. The study population heterogenicity, associated polypharmacy, multimorbidity and higher sudden unexpected death in epilepsy risks are outlined. Suggestions are made from available evidence for improving prescribing practices for PwID and seizures, and key areas for further research in this complex clinical area are outlined.
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Affiliation(s)
- David Branford
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK
| | - James J Sun
- Royal Free London NHS Foundation Trust, London, UK
| | | | - Rohit Shankar
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK
- Cornwall Intellectual Disability Equitable Research (CIDER), Cornwall Partnership NHS Foundation Trust, Truro, UK
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9
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Gabrielsson A, Tromans S, Newman H, Triantafyllopoulou P, Hassiotis A, Bassett P, Watkins L, Sawhney I, Cooper M, Griffiths L, Pullen A, Roy A, Angus-Leppan H, Rh T, Kinney M, Tittensor P, Shankar R. Awareness of social care needs in people with epilepsy and intellectual disability. Epilepsy Behav 2023; 145:109296. [PMID: 37336133 DOI: 10.1016/j.yebeh.2023.109296] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Nearly a quarter of people with intellectual disability (ID) have epilepsy with large numbers experiencing drug-resistant epilepsy, and premature mortality. To mitigate epilepsy risks the environment and social care needs, particularly in professional care settings, need to be met. PURPOSE To compare professional care groups as regards their subjective confidence and perceived responsibility when managing the need of people with ID and epilepsy. METHOD A multi-agency expert panel developed a questionnaire with embedded case vignettes with quantitative and qualitative elements to understand training and confidence in the health and social determinants of people with ID and epilepsy. The cross-sectional survey was disseminated amongst health and social care professionals working with people with ID in the UK using an exponential non-discriminative snow-balling methodology. Group comparisons were undertaken using suitable statistical tests including Fisher's exact, Kruskal-Wallis, and Mann-Whitney. Bonferroni correction was applied to significant (p < 0.05) results. Content analysis was conducted and relevant categories and themes were identified. RESULTS Social and health professionals (n = 54) rated their confidence to manage the needs of people with ID and epilepsy equally. Health professionals showed better awareness (p < 0.001) of the findings/recommendations of the latest evidence on premature deaths and identifying and managing epilepsy-related risks, including the relevance of nocturnal monitoring. The content analysis highlighted the need for clearer roles, improved care pathways, better epilepsy-specific knowledge, increased resources, and better multi-disciplinary work. CONCLUSIONS A gap exists between health and social care professionals in awareness of epilepsy needs for people with ID, requiring essential training and national pathways.
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Affiliation(s)
- A Gabrielsson
- Hertfordshire Partnership University NHS Trust, Hatfield, UK
| | - S Tromans
- University of Leicester, Leicester, UK; Leicestershire Partnership NHS Trust, Leicester, UK
| | - H Newman
- University of Plymouth Peninsula School of Medicine, Plymouth, UK
| | | | | | | | - L Watkins
- University of South Wales, Pontypridd, UK; Swansea Bay University Health Board, Port Talbot, UK
| | - I Sawhney
- Hertfordshire Partnership University NHS Trust, Hatfield, UK
| | - M Cooper
- National Development Team for Inclusion Bath, UK
| | - L Griffiths
- National Development Team for Inclusion Bath, UK
| | | | - A Roy
- Coventry and Warwickshire Partnership Trust, Birmingham, UK
| | | | | | - M Kinney
- Belfast Health and Social Trust, Belfast, UK
| | - P Tittensor
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - R Shankar
- University of Plymouth Peninsula School of Medicine, Plymouth, UK; Cornwall Partnership NHS Foundation Trust, Truro, UK.
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McMahon MJ, O'Connor AM, Dunbar P, Delany A, Behan L, Grogan C, Keyes LM. Mortality in residential care facilities for people with disability: a descriptive cross-sectional analysis of statutory notifications in Ireland. BMJ Open 2023; 13:e065745. [PMID: 37147100 PMCID: PMC10163474 DOI: 10.1136/bmjopen-2022-065745] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES To determine incidence of death in residential care facilities for people with disability in Ireland, primary cause of death, associations of facility characteristics and deaths, and to compare characteristics of deaths reported as expected and unexpected. DESIGN Descriptive cross-sectional study. SETTING All residential care facilities for people with disability operational in Ireland in 2019 and 2020 (n=1356). PARTICIPANTS n=9483 beds. MAIN OUTCOME MEASURES All expected and unexpected deaths notified to the social services regulator. Cause of death as reported by the facility. RESULTS 395 death notifications were received in 2019 (n=189) and 2020 (n=206). 45% (n=178) were for unexpected deaths. Incidence of death per 1000 beds per year was 20.83 for all, 11.44 for expected and 9.39 for unexpected deaths. Respiratory disease was the most common cause of death, accounting for 38% (n=151) of all deaths. In adjusted negative binomial regression analysis, congregated settings versus non-congregated (incidence rate ratio (95% CI): 2.59 (1.80 to 3.73)) and higher bed numbers (highest vs lowest quartile) (4.02 (2.19 to 7.40)) were positively associated with mortality. There was also a positive n-shaped association with category of nursing staff-to-resident ratio when compared with zero nurses. Emergency services were contacted for 6% of expected deaths. Of the deaths reported as unexpected, 29% were receiving palliative care and 10.8% had a terminal illness. CONCLUSION Although incidence of death was low, residents of congregated and larger settings had higher incidence of death than residents of other settings. This should be a consideration for practice and policy. Given the high contribution of respiratory diseases to deaths and the potential avoidability of these, there is a need for improved respiratory health management in this population. Nearly half of all deaths were reported as unexpected; however, overlap in the characteristics of expected and unexpected deaths highlights the need for clearer definitions.
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Affiliation(s)
- Martin J McMahon
- Health Information Quality Authority, Mahon, Cork, Ireland
- School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, Dublin 2, Ireland
- Trinity Centre for Ageing and Intellectual Disability, School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, Dublin 2, Ireland
| | | | - Paul Dunbar
- Health Information Quality Authority, Mahon, Cork, Ireland
| | - Anna Delany
- Health Information Quality Authority, Mahon, Cork, Ireland
| | - Laura Behan
- Health Information Quality Authority, Mahon, Cork, Ireland
| | - Carol Grogan
- Health Information Quality Authority, Mahon, Cork, Ireland
| | - Laura M Keyes
- Health Information Quality Authority, Mahon, Cork, Ireland
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11
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Newman H, Rudra S, Burrows L, Tromans S, Watkins L, Triantafyllopoulou P, Hassiotis A, Gabrielsson A, Shankar R. Who cares? A scoping review on intellectual disability, epilepsy and social care. Seizure 2023; 107:35-42. [PMID: 36958062 DOI: 10.1016/j.seizure.2023.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/25/2023] [Accepted: 03/01/2023] [Indexed: 03/25/2023] Open
Abstract
PURPOSE Nearly a quarter of people with Intellectual disability (PwID) have epilepsy. Many have seizures across their lifetime. In the UK supporting their epilepsy linked risks and needs, particularly in professional care settings and in the community, requires significant social care input. Therefore, the interface between social and health care services is important. This study aim is to identify key intersectional areas of social provision for PWID and epilepsy. METHODS A scoping review of the literature was performed in accordance with PRISMA guidance with suitable search terms. The search was completed in CINAHL, Embase, Psych INFO, SCIE, and Cochrane electronic databases by an information specialist. A quality assessment was completed for the included studies where appropriate. The included studies were analysed qualitatively to identify key themes and provide a narrative description of the evidence by two reviewers. RESULTS Of 748 papers screened, 94 were retrieved. Thirteen articles met the inclusion criteria with a range of methodologies. A thematic analysis generated four key categories for significant social care involvement i.e., staff training and education; emergency seizure management; holistic approach to care; and nocturnal monitoring and supervision. CONCLUSIONS PwID with epilepsy have support needs that require fulfilling by various aspects of special care provision, many within the social ambit. Inspite of evidence of these needs and recurrent calls to work jointly with social care providers this has not happened. There is limited research into social care role in epilepsy management in PwID which needs addressing.
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Affiliation(s)
- Hannah Newman
- University of Plymouth Peninsula School of Medicine, Plymouth, UK; Livewell southwest, Plymouth,UK
| | - Sonya Rudra
- Central and North London NHS Foundation Trust, London, UK
| | - Lisa Burrows
- University of Plymouth Peninsula School of Medicine, Plymouth, UK; Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Samuel Tromans
- University of Leicester, Leicester, UK; Leicestershire Partnership NHS Trust, Leicester, UK
| | - Lance Watkins
- Swansea Bay University Health Board, Port Talbot, UK; University of South Wales, Pontypridd, UK
| | | | | | | | - Rohit Shankar
- University of Plymouth Peninsula School of Medicine, Plymouth, UK; Cornwall Partnership NHS Foundation Trust, Truro, UK.
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12
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Lennard S, Newman R, McLean B, Jory C, Cox D, Young C, Corson E, Shankar R. Improving nocturnal event monitoring in people with intellectual disability in community using an artificial intelligence camera. Epilepsy Behav Rep 2023; 22:100603. [PMID: 37152695 PMCID: PMC10160340 DOI: 10.1016/j.ebr.2023.100603] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/09/2023] Open
Abstract
There is higher prevalence of epilepsy and SUDEP in people with intellectual disability (PwID) compared to general population. Accurate seizure recording particularly at night can be challenging in PwID. Neuro Event Labs seizure monitoring (Nelli) uses high-quality video based artificial intelligence to detect and record possible nocturnal seizures. This study looks to evaluate the clinical utility and acceptability of Nelli in PwID and epilepsy. Family/carers of PwID and drug resistant epilepsy with suspicions of nocturnal seizures who had not tolerated routine or ambulatory EEGs were invited to evaluate Nelli. Relevant demographics and clinical characteristics were collected. Nelli's impact, it's facilitators, barriers and feedback quality was captured from patient and professional stakeholders. Quantitative and thematic analysis was undertaken. Fifteen PwID and epilepsy and four health professionals were involved. Nelli recorded 707 possible seizure events across the study cohort of which 247 were not heard or recognised by carers. Carers recorded 165 episodes of 'restless' or "seizure behaviour" which the Nelli did not deem to be seizures. There was 93% acceptability. Thematic analysis revealed three broad themes of device acceptability, result implementation and possible seizure recognition ability. Nelli allowed for improved communication and care planning in a hitherto difficult to investigate population.
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Affiliation(s)
- Sarah Lennard
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro TR1 3QB, UK
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro TR1 3FF, UK
| | - Rachel Newman
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro TR1 3QB, UK
| | - Brendan McLean
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro TR1 3QB, UK
| | - Caryn Jory
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro TR1 3QB, UK
| | - David Cox
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro TR1 3QB, UK
| | - Charlotte Young
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro TR1 3QB, UK
| | - Eve Corson
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro TR1 3QB, UK
| | - Rohit Shankar
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro TR1 3QB, UK
- Plymouth University, Peninsula School of Medicine and Dentistry, UK
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro TR1 3FF, UK
- Corresponding author at: Threemilestone Industrial Estate, Truro, Cornwall TR4 9LD, UK.
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13
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Serrand C, Rheims S, Faucanié M, Crespel A, Dinkelacker V, Szurhaj W, Biraben A, Bartolomei F, de Grissac N, Landré E, Denuelle M, Vercueil L, Marchal C, Maillard L, Derambure P, Dupont S, Navarro V, Mura T, Jaussent A, Macioce V, Ryvlin P, Picot MC. Stratifying sudden death risk in adults with drug-resistant focal epilepsy: The SUDEP-CARE score. Eur J Neurol 2023; 30:22-31. [PMID: 36094672 PMCID: PMC10087018 DOI: 10.1111/ene.15566] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/22/2022] [Accepted: 08/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE A clinical risk score for sudden unexpected death in epilepsy (SUDEP) in patients with drug-resistant focal epilepsy could help improve prevention. METHODS A case-control study was conducted including (i) definite or probable SUDEP cases collected by the French National Sentinel Mortality Epilepsy Network and (ii) control patients from the French national research database of epilepsy monitoring units. Patients with drug-resistant focal epilepsy were eligible. Multiple logistic regressions were performed. After sensitivity analysis and internal validation, a simplified risk score was developed from the selected variables. RESULTS Sixty-two SUDEP cases and 620 controls were included. Of 21 potential predictors explored, seven were ultimately selected, including generalized seizure frequency (>1/month vs. <1/year: adjusted odds ratio [AOR] 2.6, 95% confidence interval [CI] 1.25-5.41), nocturnal or sleep-related seizures (AOR 4.49, 95% CI 2.68-7.53), current or past depression (AOR 2.0, 95% CI 1.19-3.34) or the ability to alert someone of an oncoming seizure (AOR 0.57, 95% CI 0.33-0.98). After internal validation, a clinically usable score ranging from -1 to 8 was developed, with high discrimination capabilities (area under the receiver operating curve 0.85, 95% CI 0.80-0.90). The threshold of 3 has good sensitivity (82.3%, 95% CI 72.7-91.8), whilst keeping a good specificity (82.7%, 95% CI 79.8-85.7). CONCLUSIONS These results outline the importance of generalized and nocturnal seizures on the occurrence of SUDEP, and show a protective role in the ability to alert someone of an oncoming seizure. The SUDEP-CARE score is promising and will need external validation. Further work, including paraclinical explorations, could improve this risk score.
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Affiliation(s)
- Chris Serrand
- University Hospital of Montpellier, Montpellier, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon and University of Lyon, Lyon, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sophie Dupont
- AP-HP, Epilepsy Unit, Pitié-Salpêtrière Hospital, Paris, France
| | - Vincent Navarro
- AP-HP, Epilepsy Unit, Pitié-Salpêtrière Hospital, Paris, France.,Paris Brain Institute, ICM, INSERM, CNRS, Paris, France
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14
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Kløvgaard M, Sabers A, Ryvlin P. Update on Sudden Unexpected Death in Epilepsy. Neurol Clin 2022; 40:741-754. [DOI: 10.1016/j.ncl.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Vandayar Y, Heathfield LJ. A review of the causes and risk factors for sudden unexpected death in the young. Forensic Sci Med Pathol 2022; 18:186-196. [PMID: 35133622 DOI: 10.1007/s12024-021-00444-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/28/2022]
Abstract
Sudden unexpected death in the young (SUDY) is a tragic event resulting in the fatality of seemingly healthy individuals between the ages of one and 40 years. Whilst studies have been performed on sudden unexpected death in infants, children, and adults respectively, little is known about trends in risk factors and causes of death of SUDY cases. Understanding the factors surrounding these deaths could lead to targeted interventions for at-risk individuals. Hence, a systematic approach to investigate the reported possible causes of SUDY was employed using three major databases and Primo, wherein 67 relevant articles were identified and 2 additional guidelines were read. Sudden unexpected death in epilepsy and sudden cardiac events were well-established causes of death with risk factors such as male predominance, substance use and a familial history identified. It was acknowledged that while the cause of death is established following post-mortem examination in many cases, some remain non-specific or undetermined. Considering the genetic etiology, these cases would be ideal candidates for molecular autopsies in the future. Thus, this review emphasized the significance of acquiring the relevant information to aid in resolving cause of death of these SUDY cases and subsequently highlighted the potential for further studies on risk factors and the value of molecular autopsies.
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Affiliation(s)
- Yuvika Vandayar
- Division of Forensic Medicine and Toxicology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Laura Jane Heathfield
- Division of Forensic Medicine and Toxicology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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16
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Epilepsy related multimorbidity, polypharmacy and risks in adults with intellectual disabilities: a national study. J Neurol 2022; 269:2750-2760. [DOI: 10.1007/s00415-021-10938-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/11/2021] [Indexed: 10/19/2022]
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17
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Shlobin NA, Sander JW. Reducing Sudden Unexpected Death in Epilepsy: Considering Risk Factors, Pathophysiology and Strategies. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00691-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of Review
Sudden Unexpected Death in Epilepsy (SUDEP) is the commonest cause of epilepsy-related premature mortality in people with chronic epilepsy. It is the most devastating epilepsy outcome. We describe and discuss risk factors and possible pathophysiological mechanisms to elucidate possible preventative strategies to avert SUDEP.
Recent Findings
Sudden death accounts for a significant proportion of premature mortality in people with epilepsy compared to the general population. Unmodifiable risk factors include a history of neurologic insult, younger age of seizure-onset, longer epilepsy duration, a history of convulsions, symptomatic epilepsy, intellectual disability, and non-ambulatory status. Modifiable risk factors include the presence of convulsive seizures, increased seizure frequency, timely and appropriate use of antiseizure medications, polytherapy, alcoholism, and supervision while sleeping. Pathophysiology is unclear, but several possible mechanisms such as direct alteration of cardiorespiratory function, pulmonary impairment, electrocerebral shutdown, adenosine dysfunction, and genetic susceptibility suggested.
Summary
Methods to prevent SUDEP include increasing awareness of SUDEP, augmenting knowledge of unmodifiable risk factors, obtaining full seizure remission, addressing lifestyle factors such as supervision and prone positioning, and enacting protocols to increase the detection of and intervention for SUDEP. Further studies are required to characterize precisely and comprehensively SUDEP risk factors and pathophysiological drivers and develop evidence-based algorithms to minimize SUDEP in people with epilepsy.
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O'Dwyer M, Watkins L, McCallion P, McCarron M, Henman M, Shankar R. Optimising medicines use in older adults with intellectual disability who have epilepsy: challenges and perspectives. Ther Adv Drug Saf 2021; 12:20420986211025157. [PMID: 34394909 PMCID: PMC8361510 DOI: 10.1177/20420986211025157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Maire O'Dwyer
- School of Pharmacy and Pharmaceutical Sciences, University of Dublin Trinity College, Dublin, 2, Ireland
| | - Lance Watkins
- Swansea Bay University Health Board Ringgold Standard Institution, Neath Port Talbot, UK
| | - Philip McCallion
- School of Social Work, College of Public Health, Temple University, Philadelphia, PA, USA
| | - Mary McCarron
- Trinity Centre for Ageing and Intellectual Disability, School of Nursing and Midwifery, University of Dublin, Trinity College Dublin, Ireland
| | - Martin Henman
- School of Pharmacy and Pharmaceutical Sciences, University of Dublin Trinity College, Dublin, Ireland
| | - Rohit Shankar
- Cornwall Partnership NHS Foundation Trust, Threemilestone Industrial Estate, Truro, UK, and Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, UK
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19
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Perera B, Laugharne R, Henley W, Zabel A, Lamb K, Branford D, Courtanay K, Alexander R, Purandare K, Wijeratne A, Radhakrishnan V, McNamara E, Daureeawoo Y, Sawhney I, Scheepers M, Taylor G, Shankar R. COVID-19 deaths in people with intellectual disability in the UK and Ireland: descriptive study. BJPsych Open 2020; 6:e123. [PMID: 33059790 PMCID: PMC7562776 DOI: 10.1192/bjo.2020.102] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/14/2020] [Accepted: 09/03/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Rapid spread of coronavirus disease 2019 (COVID-19) has affected people with intellectual disability disproportionately. Existing data does not provide enough information to understand factors associated with increased deaths in those with intellectual disability. Establishing who is at high risk is important in developing prevention strategies, given risk factors or comorbidities in people with intellectual disability may be different to those in the general population. AIMS To identify comorbidities, demographic and clinical factors of those individuals with intellectual disability who have died from COVID-19. METHOD An observational descriptive case series looking at deaths because of COVID-19 in people with intellectual disability was conducted. Along with established risk factors observed in the general population, possible specific risk factors and comorbidities in people with intellectual disability for deaths related to COVID-19 were examined. Comparisons between mild and moderate-to-profound intellectual disability subcohorts were undertaken. RESULTS Data on 66 deaths in individuals with intellectual disability were analysed. This group was younger (mean age 64 years) compared with the age of death in the general population because of COVID-19. High rates of moderate-to-profound intellectual disability (n = 43), epilepsy (n = 29), mental illness (n = 29), dysphagia (n = 23), Down syndrome (n = 20) and dementia (n = 15) were observed. CONCLUSIONS This is the first study exploring associations between possible risk factors and comorbidities found in COVID-19 deaths in people with intellectual disability. Our data provides insight into possible factors for deaths in people with intellectual disability. Some of the factors varied between the mild and moderate-to-profound intellectual disability groups. This highlights an urgent need for further systemic inquiry and study of the possible cumulative impact of these factors and comorbidities given the possibility of COVID-19 resurgence.
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Affiliation(s)
| | - Richard Laugharne
- Cornwall Intellectual Disability and Epilepsy Research (CIDER) Centre, Cornwall Partnership Foundation NHS Trust, UK
| | | | - Abigail Zabel
- Cornwall Intellectual Disability and Epilepsy Research (CIDER) Centre, Cornwall Partnership Foundation NHS Trust, UK
| | - Kirsten Lamb
- Royal College General Practitioners special interest group for learning disability, UK
| | | | - Ken Courtanay
- Barnet Enfield and Haringey Mental Health NHS Trust, UK
| | - Regi Alexander
- Hertfordshire Partnership University NHS Foundation Trust, UK
| | | | | | | | - Eileen McNamara
- Barnet, Enfield and Haringey Mental Health trust, Barnet Learning Disability Team, UK
| | - Youshan Daureeawoo
- Barnet, Enfield and Haringey Mental Health trust, Barnet Learning Disability Team, UK
| | | | - Mark Scheepers
- Gloucestershire Health and Care NHS Foundation Trust, UK
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20
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Schraegle WA, Young SR, Rettig EK, Payne AR, Wilson JK, Wedberg-Sivam EA, Titus JB. Improving Transitional Services for Adolescents and Young Adults with Epilepsy and Intellectual Disability. JOURNAL OF PEDIATRIC EPILEPSY 2020. [DOI: 10.1055/s-0040-1716915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractThe transition from pediatric to adult health care systems is challenging for many adolescents with epilepsy and their families, and those challenges are compounded for adolescents with comorbid intellectual disabilities and epilepsy (ID-E). Many traditional transition pathways to adult care are inadequate, as they fail to address important considerations unique to the ID-E population or are absent entirely. Poor organization of care during critical transition periods increases the risks of sudden unexpected death in epilepsy, suboptimal seizure control, inadequate management of comorbidities, and poor psychological and social outcomes. The literature lacks systematic studies on effective transition programs for this population. The present review provides an overview of the main themes important in care transitions for the ID-E population: (1) precise diagnosis and management of seizures; (2) mental health and medical comorbidities affecting care; (3) accessing behavioral, habilitative, legal, financial, and community resources; and (4) caretaker support. We propose a specific framework which includes targeted recommendations of minimum care standards for youth with ID-E transitioning to adult care.
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Affiliation(s)
- William A. Schraegle
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, Texas, United States
- Comprehensive Pediatric Epilepsy Center, UT Health Austin Pediatric Neurosciences at Dell Children's, Dell Children's Medical Center, Austin, Texas, United States
| | - Stephanie R. Young
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, Texas, United States
- Comprehensive Pediatric Epilepsy Center, UT Health Austin Pediatric Neurosciences at Dell Children's, Dell Children's Medical Center, Austin, Texas, United States
| | - Eman K. Rettig
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, Texas, United States
- Comprehensive Pediatric Epilepsy Center, UT Health Austin Pediatric Neurosciences at Dell Children's, Dell Children's Medical Center, Austin, Texas, United States
| | - Angie R. Payne
- Ascension Seton’s Comprehensive Epilepsy Program, Dell Seton Medical Center at The University of Texas, Austin, Texas, United States
| | - Janet K. Wilson
- Comprehensive Pediatric Epilepsy Center, UT Health Austin Pediatric Neurosciences at Dell Children's, Dell Children's Medical Center, Austin, Texas, United States
| | - Elizabeth A. Wedberg-Sivam
- Ascension Seton’s Comprehensive Epilepsy Program, Dell Seton Medical Center at The University of Texas, Austin, Texas, United States
| | - Jeffrey B. Titus
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, Texas, United States
- Comprehensive Pediatric Epilepsy Center, UT Health Austin Pediatric Neurosciences at Dell Children's, Dell Children's Medical Center, Austin, Texas, United States
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Deb S, Akrout Brizard B, Limbu B. Association between epilepsy and challenging behaviour in adults with intellectual disabilities: systematic review and meta-analysis. BJPsych Open 2020; 6:e114. [PMID: 32972481 PMCID: PMC7576663 DOI: 10.1192/bjo.2020.96] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Previous systematic reviews showed no significant association between epilepsy and challenging behaviours in adults with intellectual disabilities. AIMS To identify whether there is an association between epilepsy and challenging behaviour in adults with intellectual disabilities by carrying out a systematic review of published data. PROSPERO registration number: CRD42020178092. METHOD We searched five databases and hand-searched six journals. Two authors independently screened titles, abstracts and full articles using a standardised eligibility checklist. Several meta-analyses were carried out. RESULTS The narrative analysis of data from 34 included articles (14 168 adults with intellectual disabilities, 4781 of whom also had epilepsy) showed no significant association between epilepsy and challenging behaviour. Meta-analysis was possible on data from 16 controlled studies. This showed no significant intergroup difference but after sensitivity analysis meta-analysis of 10 studies showed a significantly higher rate of overall challenging behaviour in the epilepsy group (effect size: 0.16) compared with the non-epilepsy group. Aggression and self-injurious behaviour both showed a statistically significant higher rate in the epilepsy group, with very small effect sizes (0.16 and 0.28 respectively). No significant intergroup difference was observed in the rate of stereotypy. CONCLUSIONS The findings are contradictory and must be interpreted with caution because of the difficulty in pooling data from varied studies, which is likely to introduce confounding. Where significant differences were found, effect sizes are small and may not be clinically significant, and there are major methodological flaws in the included studies, which should be addressed in future large-scale properly controlled studies.
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Affiliation(s)
- Shoumitro Deb
- Faculty of Medicine, Department of Brain Sciences, Imperial College London, UK
| | - Basma Akrout Brizard
- Institut de Psychologie, Laboratoire de Psychopathologie et Processus de Santé, Paris, France
| | - Bharati Limbu
- Faculty of Medicine, Department of Brain Sciences, Imperial College London, UK
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22
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Sun JJ, Perera B, Henley W, Ashby S, Shankar R. Seizure and Sudden Unexpected Death in Epilepsy (SUDEP) characteristics in an urban UK intellectual disability service. Seizure 2020; 80:18-23. [PMID: 32485614 DOI: 10.1016/j.seizure.2020.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/25/2020] [Accepted: 05/04/2020] [Indexed: 11/24/2022] Open
Abstract
PURPOSE This study identifies epilepsy-related characteristics and SUDEP risk factors in people with epilepsy (PWE) attending an urban community ID service in the UK where managing epilepsy is not part of the service remit, to understand the care provided to this vulnerable population. METHODS An electronic database search in a north London community ID service (catchment population approx. 290,000) identified relevant ID/epilepsy characteristics in PWE to compare those with mild ID to moderate-profound ID. The SUDEP and Seizure Safety Checklist ("Checklist"), was administered to patients and families/carers. Risk management data was compared to similar data from Cornwall UK where PWE are supported within the ID service and the Checklist is used annually. RESULTS One fifth (137/697) of people attending the service had epilepsy. Over 3/4 had moderate-profound ID. Neurodevelopmental disorders were coexistent in 2/3, psychiatric conditions in 1/3 (1/4 of which was psychosis). The mean number of anti-seizure drugs was 1.45 ± 0.98, and 1/4 were taking psychotropic medications. Over a third did not have an epilepsy care plan. None contacted (n = 103) had SUDEP awareness. The median number of Checklist risk factors was seven (IQR 4.5-9). A third had experienced seizures lasting >5 min or status epilepticus. In comparison to the Cornish ID data significant differences were evident in four of seven modifiable risk factors. CONCLUSIONS This real world study highlights the complexity and risks among PWE and ID. The lack of a "joined up" approach can undermine the safety of this vulnerable population. Person-centred risk communication and care plans are easily achievable and essential.
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Affiliation(s)
- James J Sun
- Haringey Learning Disability Partnership, Barnet, Enfield and Haringey Mental Health NHS Trust, London, United Kingdom; Institute of Health Informatics, University College London, London, United Kingdom
| | - Bhathika Perera
- Haringey Learning Disability Partnership, Barnet, Enfield and Haringey Mental Health NHS Trust, London, United Kingdom
| | - William Henley
- University of Exeter Medical School, Exeter, United Kingdom
| | | | - Rohit Shankar
- University of Exeter Medical School, Exeter, United Kingdom; Cornwall Partnership NHS Foundation Trust, United Kingdom.
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23
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[Sudden unexpected death in epilepsy (SUDEP) : Epidemiology, cardiac and other risk factors]. Herzschrittmacherther Elektrophysiol 2019; 30:274-286. [PMID: 31489492 DOI: 10.1007/s00399-019-00643-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is one of the most frequent epilepsy-related causes of death. The incidence of SUDEP is estimated to be approximately 1.2/1000 person-years (PY); however, it varies considerably depending on disease-specific and demographic factors. The estimated incidence of SUDEP in children seems to be significantly lower (0.22/1000 PY) than in adults but recent studies in children (>12 years) indicated a similar incidence to that of adults. Based on these estimations, approximately 700 SUDEP cases would be expected in Germany annually but no reliable data or epidemiological studies on SUDEP are available. Various risk factors and predictors for SUDEP have been investigated, e.g. age, seizure frequency, number of antiepileptic drugs, non-compliance and comorbidities, with sometimes contradictory results. This is understandable given that the exact mechanisms of SUDEP are unclear; however, it is very likely that the frequency of (nocturnal) generalized tonic-clonic seizures is the most important risk factor. Nocturnal monitoring of seizures (using devices) or the presence of another person at night may represent important factors to reduce the risk of SUDEP. Thus, seizure control and seizure monitoring are, according to current knowledge, the most important factors to avoid SUDEP. Some recent studies have contributed to a better understanding of possible pathomechanisms of SUDEP; however, further research is needed to identify predictive clinical factors and biomarkers and in particular to prevent SUDEP.
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24
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Weltha L, Reemmer J, Boison D. The role of adenosine in epilepsy. Brain Res Bull 2019; 151:46-54. [PMID: 30468847 PMCID: PMC6527499 DOI: 10.1016/j.brainresbull.2018.11.008] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/01/2018] [Accepted: 11/15/2018] [Indexed: 12/13/2022]
Abstract
Adenosine is a well-characterized endogenous anticonvulsant and seizure terminator of the brain. Through a combination of adenosine receptor-dependent and -independent mechanisms, adenosine affects seizure generation (ictogenesis), as well as the development of epilepsy and its progression (epileptogenesis). Maladaptive changes in adenosine metabolism, in particular increased expression of the astroglial enzyme adenosine kinase (ADK), play a major role in epileptogenesis. Increased expression of ADK has dual roles in both reducing the inhibitory tone of adenosine in the brain, which consequently reduces the threshold for seizure generation, and also driving an increased flux of methyl-groups through the transmethylation pathway, thereby increasing global DNA methylation. Through these mechanisms, adenosine is uniquely positioned to link metabolism with epigenetic outcome. Therapeutic adenosine augmentation therefore not only holds promise for the suppression of seizures in epilepsy, but moreover the prevention of epilepsy and its progression overall. This review will focus on adenosine-related mechanisms implicated in ictogenesis and epileptogenesis and will discuss therapeutic opportunities and challenges.
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Affiliation(s)
- Landen Weltha
- Robert Stone Dow Neurobiology Laboratories, Legacy Research Institute, Portland, OR, USA
| | - Jesica Reemmer
- Robert Stone Dow Neurobiology Laboratories, Legacy Research Institute, Portland, OR, USA
| | - Detlev Boison
- Robert Stone Dow Neurobiology Laboratories, Legacy Research Institute, Portland, OR, USA.
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Mbizvo GK, Bennett K, Simpson CR, Duncan SE, Chin RFM. Epilepsy-related and other causes of mortality in people with epilepsy: A systematic review of systematic reviews. Epilepsy Res 2019; 157:106192. [PMID: 31526975 DOI: 10.1016/j.eplepsyres.2019.106192] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/15/2019] [Accepted: 08/25/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND This systematic review of epilepsy mortality systematic reviews evaluates comparative risks, causes, and risk factors for all-cause mortality in people with epilepsy (PWE) to specifically establish the burden of epilepsy-related deaths. METHODS MEDLINE and Embase were searched from conception to 26/12/2018 for systematic reviews evaluating all-cause mortality in PWE of any age. Independent study selection, data extraction and quality assessment were performed. Deaths were separated into epilepsy-related and unrelated using a recently published classification system. Outcomes included standardized mortality ratio (SMR) and mortality rate (MR) in a primary analysis of comparative risks, causes, and risk factors for all-cause and epilepsy-related mortality. A narrative synthesis of review findings was used to present results, including from a secondary analysis of individual epilepsy-related death risk factors. RESULTS Six moderate or high-quality systematic reviews were included in the primary analysis, evaluating 103 observational studies. All-cause mortality remained similarly high between 1950 and present (median SMR range 2.2-3.4). Africa had the highest SMR (median 5.4, range 2.6-7.2). SMRs were also higher for children <18 years (median 7.5, range 3.1-22.4) than adults (median 2.6, range 1.3-8.7), and for epilepsy-related (median 3.8, range 0.0-82.4,) than unrelated causes (median 1.7, range 0.7-17.6). Structural brain disease conferred the greatest risk for all-cause mortality (SMR range 24.0-41.5). Common epilepsy-related causes included alcohol, drowning, pneumonia, and suicide. In secondary analysis of nine additional systematic reviews, epilepsy-related death risk factors were reported for sudden unexpected death in epilepsy (SUDEP), drowning and suicide. CONCLUSIONS Premature all-cause mortality remains a major problem in PWE globally, particularly in children and young adults, with most being epilepsy-related and potentially preventable. SUDEP is only one of several other common and important epilepsy-related causes of death.
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Affiliation(s)
- Gashirai K Mbizvo
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK; Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.
| | - Kyle Bennett
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK.
| | - Colin R Simpson
- Faculty of Health, Victoria University of Wellington, Wellington, New Zealand; Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK.
| | - Susan E Duncan
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK; Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.
| | - Richard F M Chin
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK; Royal Hospital for Sick Children, Edinburgh, UK.
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The neurology-psychiatry interface in epilepsy. Ir J Psychol Med 2018; 38:9-15. [PMID: 33715646 DOI: 10.1017/ipm.2018.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Epilepsy and mental illness have a bidirectional association. Psychiatrists are likely to encounter epilepsy as comorbidity. Seizures may present as mental illness. Equally, the management of psychiatric conditions has the potential to destabilise epilepsy. There is a need for structured epilepsy awareness and training amongst psychiatrists. This paper outlines key considerations around diagnosis, treatment and risk while suggesting practical recommendations.
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Lines G, Henley W, Winterhalder R, Shankar R. Awareness, attitudes, skills and training needs of psychiatrists working with adults with intellectual disability in managing epilepsy. Seizure 2018; 63:105-112. [PMID: 30471519 DOI: 10.1016/j.seizure.2018.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Comorbid epilepsy is found in 22.5% of people with intellectual disability (ID). Responding to the continuing lack of clarity to the role of the ID psychiatrist in the United Kingdom with regards to epilepsy care, the Royal College of Psychiatrists (RCPsych) published the College Report (CR) 203 in May 2017. This proposed a three-tiered model of competency in ID epilepsy care, with minimum acceptable standards described as Bronze and greater expertise as Silver and Gold. This article documents the perceptions of ID psychiatrists as to their skills and training needs, and the perceived impact of CR203 on the profession. METHODS An e- questionnaire, matching the standards on CR203 and encouraging comments was designed, reviewed and approved by the RCPsych ID executive faculty. The survey was sent by email to all UK-registered RCPsych ID Faculty members via the RCPsych communications. RESULTS Of the expected 332 ID psychiatrists in the UK, 141 responses were received (42.4%). Key findings included that ID psychiatrists as a group have an interest in epilepsy but Bronze standards were frequently unmet, with variation across the UK. There was a noted lack of agreement on role among ID psychiatrists again linked to geographical variation. Regional disparity correlated to population density and proximity to tertiary neurological centres. CONCLUSION There are significant implications on training, both pre- and post- accreditation for the ID psychiatry speciality. The CR203 standards appear to be steps in the right direction to help define the role ID psychiatrists have in the delivery of epilepsy care.
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Affiliation(s)
- Geraldine Lines
- Oxleas NHS Foundation Trust, Pinewood Hse, Pinewood Pl, Dartford DA2 7WG, United Kingdom; King's College Medical School, United Kingdom
| | | | - Robert Winterhalder
- Oxleas NHS Foundation Trust, Pinewood Hse, Pinewood Pl, Dartford DA2 7WG, United Kingdom
| | - Rohit Shankar
- Exeter Medical School, United Kingdom; Cornwall Partnership NHS Foundation Trust, Chy Govenek, Threemilestone Industrial Estate, Truro TR4 9LD, United Kingdom.
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Ng N, Flygare Wallén E, Ahlström G. Mortality patterns and risk among older men and women with intellectual disability: a Swedish national retrospective cohort study. BMC Geriatr 2017; 17:269. [PMID: 29166873 PMCID: PMC5700486 DOI: 10.1186/s12877-017-0665-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 11/14/2017] [Indexed: 01/18/2023] Open
Abstract
Background Sweden has closed all institutions and imposed legislation to ensure service and support for individuals with intellectual disability (ID). Understanding mortality among older individuals with ID is essential to inform development of health promotion and disease control strategies. We investigated patterns and risk of mortality among older adults with ID in Sweden. Methods This retrospective cohort study compared older adults aged 55 years and older with ID with a control population. Participants were followed during 2002–2015 or death, and censored if they moved out of Sweden. Individuals with ID were identified from two national registers: one covering all specialist health-care visits (out-patient visits and hospitalisation) and the other covering people accessing social/support services. Individuals with ID (n = 15,289) were matched with a control population by sex, birth year, and year of first hospitalisation/out-patient visit/access to LSS services. Cause-of-death data were recorded using International Classification of Diseases, Tenth Revision. Cox proportional hazards regression were conducted to assess if overall and cause-specific mortality rate among individuals with ID was higher than in the Swedish population. Results The overall mortality rate among individuals with ID was 2483 per 100,000 people compared with 810 in the control population. Among those who died, more individuals with ID were younger than 75 years and unmarried. Leading causes of death among individuals with ID were circulatory diseases (34%), respiratory diseases (17%) and neoplasms (15%). Leading causes of death in a sub-sample with Down syndrome (DS) were respiratory diseases (37%), circulatory diseases (26%) and mental/behavioural disorders (11%). Epilepsy and pneumonitis were more common among individuals with ID than controls. Alzheimer’s disease was common in the control population and individuals with DS, but not among those with ID when DS was excluded. Individuals with ID had a higher overall mortality risk (hazard ratio [HR] 4.1, 95% confidence interval [CI] 4.0–4.3) and respiratory disease death risk (HR 12.5, 95% CI 10.9–14.2) than controls. Conclusion Older adults with ID in Sweden carry a higher mortality risk compared with the general population, mainly attributable to respiratory, nervous and circulatory diseases. Care for this group, particularly during the terminal stage of illness, needs to be tailored based on understanding of their main health problem. Electronic supplementary material The online version of this article (10.1186/s12877-017-0665-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nawi Ng
- Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Faculty of Medicine, Umeå University, SE-901 87, Umeå, Sweden.,Centre for Demographic and Ageing Research, Umeå University, SE-901 87, Umeå, Sweden
| | - Eva Flygare Wallén
- Karolinska Institutet (KI), Department of Neurobiology, Care Sciences and Society (NVS), Division of Family Medicine and Primary Care, Alfred Nobels allé 23, D2, SE-141 83, Huddinge, Sweden
| | - Gerd Ahlström
- Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 157, SE-221 00, Lund, Sweden.
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Carey IM, Hosking FJ, Harris T, DeWilde S, Beighton C, Cook DG. An evaluation of the effectiveness of annual health checks and quality of health care for adults with intellectual disability: an observational study using a primary care database. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05250] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
People with intellectual disability (ID) have poorer health than the general population; however, there is a lack of comprehensive national data describing their health-care needs and utilisation. Annual health checks for adults with ID have been incentivised through primary care since 2009, but only half of those eligible for such a health check receive one. It is unclear what impact health checks have had on important health outcomes, such as emergency hospitalisation.
Objectives
To evaluate whether or not annual health checks for adults with ID have reduced emergency hospitalisation, and to describe health, health care and mortality for adults with ID.
Design
A retrospective matched cohort study using primary care data linked to national hospital admissions and mortality data sets.
Setting
A total of 451 English general practices contributing data to Clinical Practice Research Datalink (CPRD).
Participants
A total of 21,859 adults with ID compared with 152,846 age-, gender- and practice-matched controls without ID registered during 2009–13.
Interventions
None.
Main outcome measures
Emergency hospital admissions. Other outcomes – preventable admissions for ambulatory care sensitive conditions, and mortality.
Data sources
CPRD, Hospital Episodes Statistics and Office for National Statistics.
Results
Compared with the general population, adults with ID had higher levels of recorded comorbidity and were more likely to consult in primary care. However, they were less likely to have long doctor consultations, and had lower continuity of care. They had higher mortality rates [hazard ratio (HR) 3.6, 95% confidence interval (CI) 3.3 to 3.9], with 37.0% of deaths classified as being amenable to health-care intervention (HR 5.9, 95% CI 5.1 to 6.8). They were more likely to have emergency hospital admissions [incidence rate ratio (IRR) 2.82, 95% CI 2.66 to 2.98], with 33.7% deemed preventable compared with 17.3% in controls (IRR 5.62, 95% CI 5.14 to 6.13). Health checks for adults with ID had no effect on overall emergency admissions compared with controls (IRR 0.96, 95% CI 0.87 to 1.07), although there was a relative reduction in emergency admissions for ambulatory care-sensitive conditions (IRR 0.82, 95% CI 0.69 to 0.99). Practices with high health check participation also showed a relative fall in preventable emergency admissions for their patients with ID, compared with practices with minimal participation (IRR 0.73, 95% CI 0.57 to 0.95). There were large variations in the health check-related content that was recorded on electronic records.
Limitations
Patients with milder ID not known to health services were not identified. We could not comment on the quality of health checks.
Conclusions
Compared with the general population, adults with ID have more chronic diseases and greater primary and secondary care utilisation. With more than one-third of deaths potentially amenable to health-care interventions, improvements in access to, and quality of, health care are required. In primary care, better continuity of care and longer appointment times are important examples that we identified. Although annual health checks can also improve access, not every eligible adult with ID receives one, and health check content varies by practice. Health checks had no impact on overall emergency admissions, but they appeared influential in reducing preventable emergency admissions.
Future work
No formal cost-effectiveness analysis of annual health checks was performed, but this could be attempted in relation to our estimates of a reduction in preventable emergency admissions.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Iain M Carey
- Population Health Research Institute, St George’s, University of London, London, UK
| | - Fay J Hosking
- Population Health Research Institute, St George’s, University of London, London, UK
| | - Tess Harris
- Population Health Research Institute, St George’s, University of London, London, UK
| | - Stephen DeWilde
- Population Health Research Institute, St George’s, University of London, London, UK
| | - Carole Beighton
- Population Health Research Institute, St George’s, University of London, London, UK
| | - Derek G Cook
- Population Health Research Institute, St George’s, University of London, London, UK
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Donner EJ, Camfield P, Brooks L, Buchhalter J, Camfield C, Loddenkemper T, Wirrell E. Understanding Death in Children With Epilepsy. Pediatr Neurol 2017; 70:7-15. [PMID: 28242084 DOI: 10.1016/j.pediatrneurol.2017.01.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/11/2017] [Indexed: 11/19/2022]
Abstract
Death in children with epilepsy is profoundly disturbing, with lasting effects on the family, community, and health care providers. The overall risk of death for children with epilepsy is about ten times that of the general population. However, the risk of premature death for children without associated neurological comorbidities is similar to that of the general population, and most deaths are related to the cause of the epilepsy or associated neurological disability, not seizures. The most common cause of seizure-related death in children with epilepsy is sudden unexpected death in epilepsy (SUDEP). SUDEP is relatively uncommon in childhood, but the risk increases if epilepsy persists into adulthood. Although the direct cause of SUDEP remains unknown, most often death follows a generalized convulsive seizure and the risk of SUDEP is strongly related to drug-resistant epilepsy and frequent generalized tonic-clonic seizures. The most effective SUDEP prevention strategy is to reduce the frequency of seizures, although a number of seizure detection devices are under development and in the future may prove to be useful for seizure detection for those at particularly high risk. There are distinct benefits for health care professionals to discuss mortality with the family soon after the diagnosis of epilepsy. An individual approach is appropriate. When a child with epilepsy dies, particularly if the death was unexpected, family grief may be profound. Physicians and other health care professionals have a critical role in supporting families that lose a child to epilepsy. This review will provide health care providers with information needed to discuss the risk of death in children with epilepsy and support families following a loss.
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Affiliation(s)
- Elizabeth J Donner
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.
| | - Peter Camfield
- Department of Pediatrics, Dalhousie University and the IWK Health Centre, Halifax, NS, Canada
| | - Linda Brooks
- The SUDEP Institute, Epilepsy Foundation, Landover, Maryland
| | - Jeffrey Buchhalter
- Department of Paediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Clinical Neuroscience, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Carol Camfield
- Department of Pediatrics, Dalhousie University and the IWK Health Centre, Halifax, NS, Canada
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Trollor J, Srasuebkul P, Xu H, Howlett S. Cause of death and potentially avoidable deaths in Australian adults with intellectual disability using retrospective linked data. BMJ Open 2017; 7:e013489. [PMID: 28179413 PMCID: PMC5306525 DOI: 10.1136/bmjopen-2016-013489] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To investigate mortality and its causes in adults over the age of 20 years with intellectual disability (ID). DESIGN, SETTING AND PARTICIPANTS Retrospective population-based standardised mortality of the ID and Comparison cohorts. The ID cohort comprised 42 204 individuals who registered for disability services with ID as a primary or secondary diagnosis from 2005 to 2011 in New South Wales (NSW). The Comparison cohort was obtained from published deaths in NSW from the Australian Bureau of Statistics (ABS) from 2005 to 2011. MAIN OUTCOME MEASURES We measured and compared Age Standardised Mortality Rate (ASMR), Comparative Mortality Figure (CMF), years of productive life lost (YPLL) and proportion of deaths with potentially avoidable causes in an ID cohort with an NSW general population cohort. RESULTS There were 19 362 adults in the ID cohort which experienced 732 (4%) deaths at a median age of 54 years. Age Standardised Mortality Rates increased with age for both cohorts. Overall comparative mortality figure was 1.3, but was substantially higher for the 20-44 (4.0) and 45-64 (2.3) age groups. YPLL was 137/1000 people in the ID cohort and 49 in the comparison cohort. Cause of death in ID cohort was dominated by respiratory, circulatory, neoplasm and nervous system. After recoding deaths previously attributed to the aetiology of the disability, 38% of deaths in the ID cohort and 17% in the comparison cohort were potentially avoidable. CONCLUSIONS Adults with ID experience premature mortality and over-representation of potentially avoidable deaths. A national system of reporting of deaths in adults with ID is required. Inclusion in health policy and services development and in health promotion programmes is urgently required to address premature deaths and health inequalities for adults with ID.
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Affiliation(s)
- Julian Trollor
- Department of Developmental Disability Neuropsychiatry, School of Psychiatry, UNSW Australia, Sydney, New South Wales, Australia
| | - Preeyaporn Srasuebkul
- Department of Developmental Disability Neuropsychiatry, School of Psychiatry, UNSW Australia, Sydney, New South Wales, Australia
| | - Han Xu
- Department of Developmental Disability Neuropsychiatry, School of Psychiatry, UNSW Australia, Sydney, New South Wales, Australia
| | - Sophie Howlett
- Department of Developmental Disability Neuropsychiatry, School of Psychiatry, UNSW Australia, Sydney, New South Wales, Australia
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Jones LA, Thomas RH. Sudden death in epilepsy: Insights from the last 25 years. Seizure 2016; 44:232-236. [PMID: 27773556 DOI: 10.1016/j.seizure.2016.10.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/03/2016] [Indexed: 12/22/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of mortality in patients with refractory epilepsy, and as such has been a major research focus over the last 25 years. The earliest SUDEP research papers were published in Seizure, as have scores of SUDEP papers since. In this review we discuss the efforts to try and describe the pathophysiological basis of SUDEP, the drive to discover the clinical risk factors that increase the likelihood of SUDEP, and the motivation to increase awareness of SUDEP. These three areas are the prime factors that, when answered, will allow us to better mitigate against SUDEP and help individuals monitor their personal risk. The field has benefited from strong definitions, multinational collaboration, the use of cutting edge genetic analysis, and ensuring that bereaved families are able to take part in research when this is appropriate. Clearly there is much that we do not know and yet, has any area of epilepsy research come so far in the last 25 years?
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Affiliation(s)
- Lliwen A Jones
- Department of Neurology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom
| | - Rhys H Thomas
- Department of Neurology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom; Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University, Hadyn Ellis Building, Maindy Road, Cardiff CF24 4HQ, United Kingdom.
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van der Lende M, Cox FME, Visser GH, Sander JW, Thijs RD. Value of video monitoring for nocturnal seizure detection in a residential setting. Epilepsia 2016; 57:1748-1753. [DOI: 10.1111/epi.13558] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Marije van der Lende
- Stichting Epilepsie Instellingen Nederland (SEIN); Heemstede The Netherlands
- Department of Neurology; Leiden University Medical Center (LUMC); Leiden The Netherlands
| | - Fieke M. E. Cox
- Stichting Epilepsie Instellingen Nederland (SEIN); Heemstede The Netherlands
| | - Gerhard H. Visser
- Stichting Epilepsie Instellingen Nederland (SEIN); Heemstede The Netherlands
| | - Josemir W. Sander
- Stichting Epilepsie Instellingen Nederland (SEIN); Heemstede The Netherlands
- Department of Clinical & Experimental Epilepsy; UCL Institute of Neurology; NIHR University College London Hospitals Biomedical Research Centre; London United Kingdom
- Epilepsy Society; Chalfont St Peter United Kingdom
| | - Roland D. Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN); Heemstede The Netherlands
- Department of Neurology; Leiden University Medical Center (LUMC); Leiden The Netherlands
- Department of Clinical & Experimental Epilepsy; UCL Institute of Neurology; NIHR University College London Hospitals Biomedical Research Centre; London United Kingdom
- Epilepsy Society; Chalfont St Peter United Kingdom
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Shankar R, Walker M, McLean B, Laugharne R, Ferrand F, Hanna J, Newman C. Steps to prevent SUDEP: the validity of risk factors in the SUDEP and seizure safety checklist: a case control study. J Neurol 2016; 263:1840-6. [DOI: 10.1007/s00415-016-8203-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 05/24/2016] [Accepted: 06/10/2016] [Indexed: 10/21/2022]
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Hosking FJ, Carey IM, Shah SM, Harris T, DeWilde S, Beighton C, Cook DG. Mortality Among Adults With Intellectual Disability in England: Comparisons With the General Population. Am J Public Health 2016; 106:1483-90. [PMID: 27310347 DOI: 10.2105/ajph.2016.303240] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To describe mortality among adults with intellectual disability in England in comparison with the general population. METHODS We conducted a cohort study from 2009 to 2013 using data from 343 general practices. Adults with intellectual disability (n = 16 666; 656 deaths) were compared with age-, gender-, and practice-matched controls (n = 113 562; 1358 deaths). RESULTS Adults with intellectual disability had higher mortality rates than controls (hazard ratio [HR] = 3.6; 95% confidence interval [CI] = 3.3, 3.9). This risk remained high after adjustment for comorbidity, smoking, and deprivation (HR = 3.1; 95% CI = 2.7, 3.4); it was even higher among adults with intellectual disability and Down syndrome or epilepsy. A total of 37.0% of all deaths among adults with intellectual disability were classified as being amenable to health care intervention, compared with 22.5% in the general population (HR = 5.9; 95% CI = 5.1, 6.8). CONCLUSIONS Mortality among adults with intellectual disability is markedly elevated in comparison with the general population, with more than a third of deaths potentially amenable to health care interventions. This mortality disparity suggests the need to improve access to, and quality of, health care among people with intellectual disability.
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Affiliation(s)
- Fay J Hosking
- At the time of the study, Fay J. Hosking, Iain M. Carey, Sunil M. Shah, Tess Harris, Stephen DeWilde, and Derek G. Cook were with the Population Health Research Institute, St George's University of London, London, England. Carole Beighton was with the Faculty of Heath Social Care and Education, Kingston and St George's, University of London
| | - Iain M Carey
- At the time of the study, Fay J. Hosking, Iain M. Carey, Sunil M. Shah, Tess Harris, Stephen DeWilde, and Derek G. Cook were with the Population Health Research Institute, St George's University of London, London, England. Carole Beighton was with the Faculty of Heath Social Care and Education, Kingston and St George's, University of London
| | - Sunil M Shah
- At the time of the study, Fay J. Hosking, Iain M. Carey, Sunil M. Shah, Tess Harris, Stephen DeWilde, and Derek G. Cook were with the Population Health Research Institute, St George's University of London, London, England. Carole Beighton was with the Faculty of Heath Social Care and Education, Kingston and St George's, University of London
| | - Tess Harris
- At the time of the study, Fay J. Hosking, Iain M. Carey, Sunil M. Shah, Tess Harris, Stephen DeWilde, and Derek G. Cook were with the Population Health Research Institute, St George's University of London, London, England. Carole Beighton was with the Faculty of Heath Social Care and Education, Kingston and St George's, University of London
| | - Stephen DeWilde
- At the time of the study, Fay J. Hosking, Iain M. Carey, Sunil M. Shah, Tess Harris, Stephen DeWilde, and Derek G. Cook were with the Population Health Research Institute, St George's University of London, London, England. Carole Beighton was with the Faculty of Heath Social Care and Education, Kingston and St George's, University of London
| | - Carole Beighton
- At the time of the study, Fay J. Hosking, Iain M. Carey, Sunil M. Shah, Tess Harris, Stephen DeWilde, and Derek G. Cook were with the Population Health Research Institute, St George's University of London, London, England. Carole Beighton was with the Faculty of Heath Social Care and Education, Kingston and St George's, University of London
| | - Derek G Cook
- At the time of the study, Fay J. Hosking, Iain M. Carey, Sunil M. Shah, Tess Harris, Stephen DeWilde, and Derek G. Cook were with the Population Health Research Institute, St George's University of London, London, England. Carole Beighton was with the Faculty of Heath Social Care and Education, Kingston and St George's, University of London
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Devinsky O, Asato M, Camfield P, Geller E, Kanner AM, Keller S, Kerr M, Kossoff EH, Lau H, Kothare S, Singh BK, Wirrell E. Delivery of epilepsy care to adults with intellectual and developmental disabilities. Neurology 2015; 85:1512-21. [PMID: 26423430 PMCID: PMC4631073 DOI: 10.1212/wnl.0000000000002060] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 05/28/2015] [Indexed: 11/15/2022] Open
Abstract
Epilepsy is common in people with intellectual and developmental disabilities (IDD). In adulthood, patients with IDD and epilepsy (IDD-E) have neurologic, psychiatric, medical, and social challenges compounded by fragmented and limited care. With increasing neurologic disability, there is a higher frequency of epilepsy, especially symptomatic generalized and treatment-resistant epilepsies. The causes of IDD-E are increasingly recognized to be genetic based on chromosomal microarray analysis to identify copy number variants, gene panels (epilepsy, autism spectrum disorder, intellectual disability), and whole-exome sequencing. A specific genetic diagnosis may guide care by pointing to comorbid disorders and best therapy. Therapy to control seizures should be individualized, with drug selection based on seizure types, epilepsy syndrome, concomitant medications, and comorbid disorders. There are limited comparative antiepileptic drug data in the IDD-E population. Vagus nerve and responsive neural stimulation therapies and resective surgery should be considered. Among the many comorbid disorders that affect patients with IDD-E, psychiatric and sleep disorders are common but often unrecognized and typically not treated. Transition from holistic and coordinated pediatric to adult care is often a vulnerable period. Communication among adult health care providers is complex but essential to ensure best care when these patients are seen in outpatient, emergency room, and inpatient settings. We propose specific recommendations for minimum care standards for people with IDD-E.
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Affiliation(s)
- Orrin Devinsky
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN.
| | - Miya Asato
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN
| | - Peter Camfield
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN
| | - Eric Geller
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN
| | - Andres M Kanner
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN
| | - Seth Keller
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN
| | - Michael Kerr
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN
| | - Eric H Kossoff
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN
| | - Heather Lau
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN
| | - Sanjeev Kothare
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN
| | - Baldev K Singh
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN
| | - Elaine Wirrell
- From New York University School of Medicine (O.D., H.L., S.K.), New York; Children's Hospital of Pittsburgh of UPMC (M.A.), PA; IWK Heath Centre and Dalhousie University (P.C.), Halifax, Canada; Saint Barnabas Medical Center (E.G.), Livingston, NJ; University of Miami Miller School of Medicine (A.M.K.), FL; Advocare Neurology of South Jersey (S.K.), Lumberton, NJ; Welsh Centre for Learning Disabilities (M.K.), Cardiff University, Cathays, Cardiff, UK; Johns Hopkins Hospital (E.H.K.), Baltimore, MD; New York Medical College (B.K.S.), New York; and Mayo Clinic Hospital (E.W.), Rochester, MN
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