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Liu C, Ye J, He S, Ma Z, Luo F, Miao J, Li H, Cao P, Zhu J. Causal relationship between rheumatoid arthritis and epilepsy in a European population: a univariate and multivariate Mendelian randomization study. Front Immunol 2024; 15:1389549. [PMID: 38817604 PMCID: PMC11137193 DOI: 10.3389/fimmu.2024.1389549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/06/2024] [Indexed: 06/01/2024] Open
Abstract
Background Several previous studies have reported an association between rheumatoid arthritis (RA) and epilepsy, but the causal relationship is unclear. The aim of this study was to assess the connection between RA and epilepsy in a European population using Mendelian randomization (MR). Methods Genome-wide association study summary data on RA and epilepsy from European populations were included. Univariate MR (UVMR) and multivariate MR were used to investigate the causal relationship between the two conditions. Three analysis methods were applied: inverse variance weight (IVW), MR-Egger, and weighted median, with IVW being the primary method. Cochran Q statistics, MR-PRESSO, MR-Egger intercept, leave-one-out test, and MR-Steiger test were combined for the sensitivity analysis. Results UVMR showed a positive association between RA and epilepsy risk (OR=1.038, 95% CI=1.007-1.038, p=0.017) that was supported by sensitivity analysis. Further MVMR after harmonizing the three covariates of hypertension, alcohol consumption, and smoking, confirmed the causal relationship between RA and epilepsy (OR=1.049, 95% CI=1.011-1.087, p=0.010). Conclusion This study demonstrated that RA is associated with an increased risk of epilepsy. It has emphasized that the monitoring of epilepsy risk in patients diagnosed with RA should be strengthened in clinical practice, and further studies are needed in the future to explore the potential mechanism of action connecting the two conditions.
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Affiliation(s)
- Chang Liu
- School of Acupuncture-Moxibustion and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
- The Third Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jiangnan Ye
- School of Acupuncture-Moxibustion and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Shixiu He
- Arthrology Department, Nanchong Gaoping District People’s Hospital, Nanchong, Sichuan, China
| | - Zhijun Ma
- School of Acupuncture-Moxibustion and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Fang Luo
- School of Acupuncture-Moxibustion and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jintao Miao
- The Third Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Huinan Li
- The Third Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Puhua Cao
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jun Zhu
- School of Acupuncture-Moxibustion and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
- The Third Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
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Gotlieb E, Agarwal P, Blank LJ, Kwon CS, Muxfeldt M, Young JJ, Jette N. Disparities in Teleneurology Use in Medicaid Beneficiaries With Epilepsy by Practice Setting: Promoting Health Equity in Academic Centers. Neurology 2024; 102:e209348. [PMID: 38608210 PMCID: PMC11175647 DOI: 10.1212/wnl.0000000000209348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 02/13/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Medicaid beneficiaries in many American academic medical centers can receive care in a separate facility than those not covered by Medicaid. We aimed to identify possible disparities in care by evaluating the association between facility type (integrated faculty practice or Medicaid-only outpatient clinic) and telehealth utilization in people with epilepsy. METHODS We performed retrospective analyses using structured data from the Mount Sinai Health System electronic medical record data from January 2003 to August 2021. We identified people of all ages with epilepsy who were followed by an epileptologist after January 3, 2018, using a validated ICD-9-CM/10-CM coded case definition. We evaluated associations between practice setting and telehealth utilization, an outcome measure that captures the evolving delivery of neurologic care in a post-coronavirus disease 2019 era, using multivariable logistic regression. RESULTS We identified 4,586 people with epilepsy seen by an epileptologist, including Medicaid beneficiaries in the Medicaid outpatient clinic (N = 387), Medicaid beneficiaries in the faculty practice after integration (N = 723), and non-Medicaid beneficiaries (N = 3,476). Patients not insured by Medicaid were significantly older (average age 40 years vs 29 in persons seen in Medicaid-only outpatient clinic and 28.5 in persons insured with Medicaid seen in faculty practice [p < 0.0001]). Medicaid beneficiaries were more likely to have drug-resistant epilepsy (DRE), with 51.94% of people seen in Medicaid-only outpatient clinic, 41.63% of Medicaid beneficiaries seen in faculty practice, and 37.2% of non-Medicaid beneficiaries having DRE (p < 0.0001). Medicaid outpatient clinic patients were less likely to have telehealth visits (phone or video); 81.65% of patients in the Medicaid outpatient clinic having no telehealth visits vs 71.78% of Medicaid beneficiaries in the faculty practice and 70.89% of non-Medicaid beneficiaries (p < 0.0001). In an adjusted logistic regression analysis, Medicaid beneficiaries had lower odds (0.61; 95% CI 0.46-0.81) of using teleneurology compared with all patients seen in faculty practice (p = 0.0005). DISCUSSION Compared with the Medicaid-only outpatient clinic, we found higher telehealth utilization in the integrated faculty practice with no difference by insurance status (Medicaid vs other). Integrated care may be associated with better health care delivery in people with epilepsy; thus, future research should examine its impact on other epilepsy-related outcomes.
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Affiliation(s)
- Evelyn Gotlieb
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - Parul Agarwal
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - Leah J Blank
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - Churl-Su Kwon
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - Maria Muxfeldt
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - James J Young
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - Nathalie Jette
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
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Bensken WP, Vaca GFB, Williams SM, Khan OI, Jobst BC, Stange KC, Sajatovic M, Koroukian SM. Disparities in adherence and emergency department utilization among people with epilepsy: A machine learning approach. Seizure 2023; 110:169-176. [PMID: 37393863 PMCID: PMC10528555 DOI: 10.1016/j.seizure.2023.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/22/2023] [Accepted: 06/25/2023] [Indexed: 07/04/2023] Open
Abstract
PURPOSE We used a machine learning approach to identify the combinations of factors that contribute to lower adherence and high emergency department (ED) utilization. METHODS Using Medicaid claims, we identified adherence to anti-seizure medications and the number of ED visits for people with epilepsy in a 2-year follow up period. We used three years of baseline data to identify demographics, disease severity and management, comorbidities, and county-level social factors. Using Classification and Regression Tree (CART) and random forest analyses we identified combinations of baseline factors that predicted lower adherence and ED visits. We further stratified these models by race and ethnicity. RESULTS From 52,175 people with epilepsy, the CART model identified developmental disabilities, age, race and ethnicity, and utilization as top predictors of adherence. When stratified by race and ethnicity, there was variation in the combinations of comorbidities including developmental disabilities, hypertension, and psychiatric comorbidities. Our CART model for ED utilization included a primary split among those with previous injuries, followed by anxiety and mood disorders, headache, back problems, and urinary tract infections. When stratified by race and ethnicity we saw that for Black individuals headache was a top predictor of future ED utilization although this did not appear in other racial and ethnic groups. CONCLUSIONS ASM adherence differed by race and ethnicity, with different combinations of comorbidities predicting lower adherence across racial and ethnic groups. While there were not differences in ED use across races and ethnicity, we observed different combinations of comorbidities that predicted high ED utilization.
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Affiliation(s)
- Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
| | - Guadalupe Fernandez-Baca Vaca
- Department of Neurology, University Hospitals Cleveland Medical Center, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Scott M Williams
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Omar I Khan
- Epilepsy Center of Excellence, Baltimore VA Medical Center, US Department of Veterans Affairs, Baltimore, MD, USA
| | - Barbara C Jobst
- Department of Neurology, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, NH, Lebanon, USA
| | - Kurt C Stange
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA; Center for Community Health Integration, Departments of Family Medicine & Community Health, and Sociology, Case Western Reserve University, Cleveland, OH, USA
| | - Martha Sajatovic
- Departments of Neurology and Psychiatry, University Hospitals Cleveland Medical Center, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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Moon HJ, Lee H, Yoon D, Koo YS, Shin JY, Lee SY. Premature Mortality and Causes of Death Among People With Epilepsy: A Nationwide Population-Based Incident Cohort Study. Neurology 2023; 100:e2060-e2070. [PMID: 36948594 PMCID: PMC10186245 DOI: 10.1212/wnl.0000000000207212] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 02/07/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND AND OBJECTIVES People with epilepsy (PWE) are at risk of premature death with considerable variability according to the study population. We aimed to estimate the risk and causes of death in PWE according to age, disease severity, disease course, comorbidities, and socioeconomic status in Korea. METHODS We conducted a nationwide population-based retrospective cohort study using the National Health Insurance database linked with the national death register. Newly treated PWE from 2008 to 2016 who were identified by antiseizure medication (ASM) prescriptions and diagnostic codes for epilepsy/seizure were included and observed until 2017. We assessed all-cause and cause-specific crude mortality rates and standardized mortality ratios (SMRs). RESULTS Among 138,998 PWE, 20,095 deaths were identified, and the mean follow-up period was 4.79 years. The SMR was 2.25 in the overall group of PWE, with a higher value in the younger age group at diagnosis and a shorter time interval after diagnosis. The SMR in the monotherapy group was 1.56, while that in the group with 4 or more ASMs was 4.93. PWE without any comorbidities had an SMR of 1.61. PWE who were rural residents had a higher SMR than those who were urban residents (2.47 vs 2.03, respectively). The causes of death among PWE were cerebrovascular disease (18.9%, SMR 4.50), malignant neoplasms outside the CNS (15.7%, SMR 1.37), malignant neoplasms of the CNS (6.7%, SMR 46.95), pneumonia (6.0%, SMR 2.08), and external causes (7.2%, SMR 2.17), including suicide (2.6%, SMR 2.07). Epilepsy itself and status epilepticus accounted for 1.9% of the overall death. The excess mortality associated with pneumonia and external causes was persistently high, whereas the excess mortality associated with malignancy and cerebrovascular diseases tended to decrease with increasing time since diagnosis. DISCUSSION This study showed excess mortality in PWE, even in those without comorbidities and those receiving monotherapy. Regional disparities and sustained risks of deaths from external causes over 10 years imply potential points of intervention. In addition to active control of seizures, education about injury prevention, monitoring for suicidal ideation, and efforts to improve accessibility to epilepsy care are all required to reduce mortality.
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Affiliation(s)
- Hye-Jin Moon
- From the Department of Neurology (H.-J.M.), Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine; Department of Biohealth Regulatory Science (H.L., D.Y., J.-Y.S.), School of Pharmacy, Sungkyunkwan University, Suwon; Department of Neurology (Y.S.K.), Asan Medical Center, Seoul; Samsung Advanced Institute for Health Sciences & Technology (SAIHST) (J.-Y.S.), Sungkyunkwan University, Seoul; Department of Neurology (S.-Y.L.), College of Medicine, Kangwon National University, Chuncheon; and Interdisciplinary Graduate Program in Medical Bigdata Convergence (S.-Y.L.), Kangwon National University, Chuncheon, South Korea
| | - Hyesung Lee
- From the Department of Neurology (H.-J.M.), Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine; Department of Biohealth Regulatory Science (H.L., D.Y., J.-Y.S.), School of Pharmacy, Sungkyunkwan University, Suwon; Department of Neurology (Y.S.K.), Asan Medical Center, Seoul; Samsung Advanced Institute for Health Sciences & Technology (SAIHST) (J.-Y.S.), Sungkyunkwan University, Seoul; Department of Neurology (S.-Y.L.), College of Medicine, Kangwon National University, Chuncheon; and Interdisciplinary Graduate Program in Medical Bigdata Convergence (S.-Y.L.), Kangwon National University, Chuncheon, South Korea.
| | - Dongwon Yoon
- From the Department of Neurology (H.-J.M.), Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine; Department of Biohealth Regulatory Science (H.L., D.Y., J.-Y.S.), School of Pharmacy, Sungkyunkwan University, Suwon; Department of Neurology (Y.S.K.), Asan Medical Center, Seoul; Samsung Advanced Institute for Health Sciences & Technology (SAIHST) (J.-Y.S.), Sungkyunkwan University, Seoul; Department of Neurology (S.-Y.L.), College of Medicine, Kangwon National University, Chuncheon; and Interdisciplinary Graduate Program in Medical Bigdata Convergence (S.-Y.L.), Kangwon National University, Chuncheon, South Korea
| | - Yong Seo Koo
- From the Department of Neurology (H.-J.M.), Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine; Department of Biohealth Regulatory Science (H.L., D.Y., J.-Y.S.), School of Pharmacy, Sungkyunkwan University, Suwon; Department of Neurology (Y.S.K.), Asan Medical Center, Seoul; Samsung Advanced Institute for Health Sciences & Technology (SAIHST) (J.-Y.S.), Sungkyunkwan University, Seoul; Department of Neurology (S.-Y.L.), College of Medicine, Kangwon National University, Chuncheon; and Interdisciplinary Graduate Program in Medical Bigdata Convergence (S.-Y.L.), Kangwon National University, Chuncheon, South Korea
| | - Ju-Young Shin
- From the Department of Neurology (H.-J.M.), Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine; Department of Biohealth Regulatory Science (H.L., D.Y., J.-Y.S.), School of Pharmacy, Sungkyunkwan University, Suwon; Department of Neurology (Y.S.K.), Asan Medical Center, Seoul; Samsung Advanced Institute for Health Sciences & Technology (SAIHST) (J.-Y.S.), Sungkyunkwan University, Seoul; Department of Neurology (S.-Y.L.), College of Medicine, Kangwon National University, Chuncheon; and Interdisciplinary Graduate Program in Medical Bigdata Convergence (S.-Y.L.), Kangwon National University, Chuncheon, South Korea.
| | - Seo-Young Lee
- From the Department of Neurology (H.-J.M.), Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine; Department of Biohealth Regulatory Science (H.L., D.Y., J.-Y.S.), School of Pharmacy, Sungkyunkwan University, Suwon; Department of Neurology (Y.S.K.), Asan Medical Center, Seoul; Samsung Advanced Institute for Health Sciences & Technology (SAIHST) (J.-Y.S.), Sungkyunkwan University, Seoul; Department of Neurology (S.-Y.L.), College of Medicine, Kangwon National University, Chuncheon; and Interdisciplinary Graduate Program in Medical Bigdata Convergence (S.-Y.L.), Kangwon National University, Chuncheon, South Korea.
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Bensken WP, Alberti PM, Khan OI, Williams SM, Stange KC, Vaca GFB, Jobst BC, Sajatovic M, Koroukian SM. A framework for health equity in people living with epilepsy. Epilepsy Res 2022; 188:107038. [PMID: 36332544 PMCID: PMC9797034 DOI: 10.1016/j.eplepsyres.2022.107038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/22/2022] [Accepted: 10/17/2022] [Indexed: 12/31/2022]
Abstract
Epilepsy is a disease where disparities and inequities in risk and outcomes are complex and multifactorial. While most epilepsy research to date has identified several key areas of disparities, we set out to provide a multilevel life course model of epilepsy development, diagnosis, treatment, and outcomes to highlight how these disparities represent true inequities. Our piece also presents three hypothetical cases that highlight how the solutions to address inequities may vary across the lifespan. We then identify four key domains (structural, socio-cultural, health care, and physiological) that contribute to the persistence of inequities in epilepsy risk and outcomes in the United States. Each of these domains, and their core components in the context of epilepsy, are reviewed and discussed. Further, we highlight the connection between domains and key areas of intervention to strive towards health equity. The goal of this work is to highlight these domains while also providing epilepsy researchers and clinicians with broader context of how their work fits into health equity.
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Affiliation(s)
- Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA.
| | - Philip M Alberti
- AAMC Center for Health Justice, Association of American Medical Colleges, Washington, DC, USA
| | - Omar I Khan
- Epilepsy Center of Excellence, Baltimore VA Medical Center US Department of Veterans Affairs, Baltimore, MD, USA
| | - Scott M Williams
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Department of Genetics and Genome Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Kurt C Stange
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Center for Community Health Integration, Departments of Family Medicine & Community Health, and Sociology Case Western Reserve University, Cleveland, OH, USA
| | - Guadalupe Fernandez-Baca Vaca
- Department of Neurology, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Barbara C Jobst
- Department of Neurology, Geisel School of Medicine Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Martha Sajatovic
- Department of Neurology, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Department Psychiatry, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA
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Haneef Z, Rehman R, Husain AM. Association Between Standardized Mortality Ratio and Utilization of Care in US Veterans With Drug-Resistant Epilepsy Compared With All US Veterans and the US General Population. JAMA Neurol 2022; 79:879-887. [PMID: 35969384 PMCID: PMC9379823 DOI: 10.1001/jamaneurol.2022.2290] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/24/2022] [Indexed: 11/14/2022]
Abstract
Importance Drug-resistant epilepsy (DRE) is thought to be associated with increased mortality, but larger population-based studies are lacking. Additionally, the benefit of effective management in DRE lacks evidence. Objective To examine the association of utilization of care with mortality in US veterans with DRE. Design, Setting, and Participants Observational cohort study conducted between October 1, 2013, and March 31, 2020. Mortality statistics in US veterans with DRE were compared to the US general population and all veterans within the Veterans Health Administration. Epilepsy was defined as use of 1 or more antiseizure medications (ASMs) for 30 days or longer with a seizure diagnosis or 1 inpatient or 2 outpatient encounters with an epilepsy diagnosis. DRE was defined as the use of 2 or more ASMs. Among 9.6 million US veterans, 164 435 (1.7%) had epilepsy, of whom 55 571 (33.8%) had DRE. Epilepsy and DRE were administratively identified based on criteria noted in design. Identified participants were included for analysis. Exposures Veterans with DRE. Main Outcomes and Measures Standardized mortality ratio (SMR). Results Among US veterans with DRE, the mean (SD) age was 58.3 (15.4) years, and 49 430 individuals (88.9%) were male. Of ethnicity data gathered, 3170 individuals (5.7%) were Hispanic or Latino, 50 599 (91.1%) were not Hispanic or Latino, 842 (1.5%) declined to answer, and 960 (1.7%) were recorded as unknown. Of race data gathered, 516 individuals (0.9%) were American Indian or Alaskan Native, 270 (0.5%) were Asian, 11 316 (20.4%) were Black or African American, 587 (1.1%) were of multiple races, 453 (0.8%) were Native Hawaiian or Pacific Islander, 39 543 (71.2%) were White, 1697 (3.1%) declined to answer, and 1189 (2.1%) were recorded as unknown. SMR was 1.50 (95% CI, 1.47-1.53) compared with the US general population and 1.56 (95% CI, 1.53-1.59) compared with all veterans. Utilization rates were 81.1% (n = 45 057) for neurology clinic evaluation, 66.4% (n = 36 905) for magnetic resonance imaging (MRI), and 49.6% (n = 27 546) for electroencephalography (EEG) testing. Only 8350 individuals (15.0%) had comprehensive epilepsy evaluations and 3357 (6.0%) had epilepsy monitoring. Multivariable analysis revealed an association between lower mortality and neurology clinic evaluation, EEG, MRI, epilepsy monitoring, and the use of more than 2 ASMs after adjusting for age and comorbidities. Conclusions and Relevance Mortality rates were significantly higher in US veterans with DRE compared to the general population. Better utilization of comprehensive epilepsy care, diagnostic services, and medications were each associated with reduced mortality. These findings indicate that appropriate management of DRE is critical in this population.
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Affiliation(s)
- Zulfi Haneef
- Neurology Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Neurology, Baylor College of Medicine, Houston, Texas
- Epilepsy Centers of Excellence (ECoE), Veterans Health Administration, Durham, North Carolina
| | - Rizwana Rehman
- Epilepsy Centers of Excellence (ECoE), Veterans Health Administration, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Aatif M. Husain
- Epilepsy Centers of Excellence (ECoE), Veterans Health Administration, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
- Duke University, Durham, North Carolina
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Peden AE, Taylor DH, Franklin RC. Pre-Existing Medical Conditions: A Systematic Literature Review of a Silent Contributor to Adult Drowning. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:8863. [PMID: 35886717 PMCID: PMC9324568 DOI: 10.3390/ijerph19148863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022]
Abstract
Medical conditions can increase drowning risk. No prior study has systematically reviewed the published evidence globally regarding medical conditions and drowning risk for adults. MEDLINE (Ovid), PubMed, EMBASE, Scopus, PsycINFO (ProQuest) and SPORTDiscus databases were searched for original research published between 1 January 2005 and 31 October 2021 that reported adult (≥15 years) fatal or non-fatal drowning of all intents and pre-existing medical conditions. Conditions were grouped into the relevant International Classifications of Diseases (ICD) codes. Eighty-three studies were included (85.5% high-income countries; 38.6% East Asia and Pacific region; 75.9% evidence level III-3). Diseases of the nervous system (n = 32 studies; 38.6%), mental and behavioural conditions (n = 31; 37.3%) and diseases of the circulatory system (n = 25; 30.1%) were the most common categories of conditions. Epilepsy was found to increase the relative risk of drowning by 3.8 to 82 times, with suggested preventive approaches regarding supervised bathing or showering. Drowning is a common suicide method for those with schizophrenia, psychotic disorders and dementia. Review findings indicate people with pre-existing medical conditions drown, yet relatively few studies have documented the risk. There is a need for further population-level research to more accurately quantify drowning risk for pre-existing medical conditions in adults, as well as implementing and evaluating population-level attributable risk and prevention strategies.
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Affiliation(s)
- Amy E. Peden
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Kensington, NSW 2052, Australia;
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia;
| | - Danielle H. Taylor
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia;
| | - Richard C. Franklin
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia;
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Abstract
PURPOSE OF REVIEW Sudden unexpected death in epilepsy (SUDEP) is a major contributor to premature mortality in people with epilepsy. This review provides an update on recent findings on the epidemiology of SUDEP, clinical risk factors and potential mechanisms. RECENT FINDINGS The overall risk rate of SUDEP is approximately 1 per 1000 patients per year in the general epilepsy population and that children and older adults have a similar incidence. Generalized convulsive seizures (GCS), perhaps through their effects on brainstem cardiopulmonary networks, can cause significant postictal respiratory and autonomic dysfunction though other mechanisms likely exist as well. Work in animal models of SUDEP has identified multiple neurotransmitter systems, which may be future targets for pharmacological intervention. There are also chronic functional and structural changes in autonomic function in patients who subsequently die from SUDEP suggesting that some SUDEP risk is dynamic. Modifiable risks for SUDEP include GCS seizure frequency, medication adherence and nighttime supervision. SUMMARY Current knowledge of SUDEP risk factors has identified multiple targets for SUDEP prevention today as we await more specific therapeutic targets that are emerging from translational research studies.
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Affiliation(s)
- Daniel Friedman
- NYU Grossman School of Medicine, Department of Neurology, 223 East 34th Street, New York, New York, USA
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9
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Devinsky O. Epilepsy Mortality: The Unseen and Unknown. Neurology 2021; 98:93-94. [PMID: 34795044 DOI: 10.1212/wnl.0000000000013069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Orrin Devinsky
- Department of Neurology, New York University Grossman School of Medicine
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10
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Takeda K, Yamashita S, Taniguchi G, Kuramochi I, Murakami M, Kashiwagi H, Hashimoto R, Hirabayashi N, Okada T. Criminal victimization of people with epilepsy: Sixteen criminal judgments in Japan between 1990 and 2019. Epilepsy Behav 2021; 118:107912. [PMID: 33744796 DOI: 10.1016/j.yebeh.2021.107912] [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: 01/17/2021] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 11/30/2022]
Abstract
Criminal behavior by people with epilepsy (PWE) has often been discussed. However, there are limited studies on criminal victimization of PWE-in particular, how such victimizations occur. We identified criminal cases involving victims with epilepsy using databases containing criminal judgments and found 16 such cases between 1990 and 2019. Seven were homicide cases, including four filicide cases. In the four filicide cases, all the perpetrators had the intention of homicide-suicide; all the victims had intellectual disabilities or cerebral palsy; two of these victims had acted violently toward the family; and two mothers who perpetrated the crime against the victims had depression. It seemed that the comorbidities and problem behaviors of the victims were more strongly related to serious crimes by family caregivers than the epilepsy itself. To prevent victimization caused by family caregivers, reducing their stress levels is important. Defendants sometimes argued against objective evidence of a crime, claiming that epileptic seizure of PWE caused or was related to the death of victims. Legal and medical professionals involved in determining the manner of death need careful evaluation when sudden deaths of PWE occur.
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Affiliation(s)
- Koji Takeda
- Department of Psychiatry, National Center of Neurology and Psychiatry Hospital, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan; Section of Psychiatry and Behavioral Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan; Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8553, Japan.
| | - Shingo Yamashita
- Department of Psychiatry, National Center of Neurology and Psychiatry Hospital, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan
| | - Go Taniguchi
- Department of Psychiatry, National Center of Neurology and Psychiatry Hospital, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan
| | - Izumi Kuramochi
- Department of Psychiatry, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe-shi, Saitama 350-0844, Japan
| | - Maki Murakami
- Department of Psychiatry, National Center of Neurology and Psychiatry Hospital, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan
| | - Hiroko Kashiwagi
- Department of Psychiatry, National Center of Neurology and Psychiatry Hospital, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan; Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8553, Japan
| | - Ryota Hashimoto
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8553, Japan
| | - Naotsugu Hirabayashi
- Department of Psychiatry, National Center of Neurology and Psychiatry Hospital, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan
| | - Takayuki Okada
- Section of Psychiatry and Behavioral Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
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11
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Khor SB, Lim KS, Fong SL, Ho JH, Koh MY, Tan CT. Mortality in adult epilepsy patients in Malaysia: a hospital-based study. Seizure 2021; 88:56-59. [PMID: 33812309 DOI: 10.1016/j.seizure.2021.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND The standardized mortality ratio (SMR) of epilepsy in Asia ranges from 2.5 to 5.1. However, there are no such published data in Malaysia to date. Understanding the mortality rate and related factors will allow us to better assess and monitor the health status of PWE, thereby, preventing premature deaths among PWE. Hence, this study aimed to determine the mortality rate of adults with epilepsy (PWE) at the University Malaya Medical Centre (UMMC), a tertiary hospital in Malaysia. METHOD A total of 2218 PWE were recruited retrospectively into this study. Deceased cases from 2009-2018 were identified from the National Registry Department of Malaysia. Age-, gender-, and ethnic-specific SMR were calculated. RESULT There was a total of 163 deaths, of which 111 (68.1%) were male. The overall case-fatality rate (CFR) was 7.3%. Male PWE had higher CFR (9.2%) compared to females (5.1%, p<0.001). The annual death rate of PWE was 867 per 100, 000 persons. The overall all-cause SMR was 1.6 (CI 95% 1.3-1.8). The SMR for younger age groups (15-19 and 20-29 years) were higher (5.4-5.5) compared to other age groups (0.4-2.5). Overall SMR for male PWE (1.8, 95% CI 1.5-2.1) was higher than females (1.2, 95% CI 0.9-1.6). However, the SMR for female PWE in the younger age groups (15-19, 20-29 and 30-39 years) was higher. SMR among the Indian PWE was the highest (1.6, 95% CI 1.2-2.0) compared to the Chinese (1.5, 95% CI 1.2-1.9) and the Malays (1.4, 95% 1.0-1.9). The CFR was higher in those with focal epilepsy (8.5% vs. 2.5-3.7% in genetic and other generalized epilepsies, p=0.003), epilepsy with structural cause (9.5% vs. 5.9% in others, p=0.005) and uncontrolled seizures (7.9% vs. 5.2% in seizure-free group, p<0.001). CONCLUSION The mortality rate of PWE in Malaysia is higher than that of the general population but lower compared to other Asian countries. Specifically, the rates are higher in the younger age group, male gender, and Indian ethnicity. Those with focal epilepsy, structural causes and uncontrolled seizures have higher mortality rates.
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Affiliation(s)
- Si Bao Khor
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kheng-Seang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Si-Lei Fong
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jun Hui Ho
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - May Yi Koh
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chong-Tin Tan
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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12
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Harowitz J, Crandall L, McGuone D, Devinsky O. Seizure-related deaths in children: The expanding spectrum. Epilepsia 2021; 62:570-582. [PMID: 33586153 PMCID: PMC7986159 DOI: 10.1111/epi.16833] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 12/26/2022]
Abstract
Although seizures are common in children, they are often overlooked as a potential cause of death. Febrile and nonfebrile seizures can be fatal in children with or without an epilepsy diagnosis and may go unrecognized by parents or physicians. Sudden unexpected infant deaths, sudden unexplained death in childhood, and sudden unexpected death in epilepsy share clinical, neuropathological, and genetic features, including male predominance, unwitnessed deaths, death during sleep, discovery in the prone position, hippocampal abnormalities, and variants in genes regulating cardiac and neuronal excitability. Additionally, epidemiological studies reveal that miscarriages are more common among individuals with a personal or family history of epilepsy, suggesting that some fetal losses may result from epileptic factors. The spectrum of seizure-related deaths in pediatrics is wide and underappreciated; accurately estimating this mortality and understanding its mechanism in children is critical to developing effective education and interventions to prevent these tragedies.
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Affiliation(s)
- Jenna Harowitz
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura Crandall
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, USA.,SUDC Foundation, Herndon, Virginia, USA
| | - Declan McGuone
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, USA
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13
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Verducci C, Friedman D, Donner EJ, Laze J, Devinsky O. SUDEP classification: Discordances between forensic investigators and epileptologists. Epilepsia 2020; 61:e173-e178. [PMID: 33063853 DOI: 10.1111/epi.16712] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/28/2020] [Accepted: 09/09/2020] [Indexed: 11/28/2022]
Abstract
We compared sudden unexpected death in epilepsy (SUDEP) diagnosis rates between North American SUDEP Registry (NASR) epileptologists and original death investigators, to determine degree and causes of discordance. In 220 SUDEP cases with post-mortem examination, we recorded the epileptologist adjudications and medical examiner- and coroner- (ME/C) listed causes of death (CODs). COD diagnosis concordance decreased with NASR's uncertainty in the SUDEP diagnosis: highest for Definite SUDEP (84%, n = 158), lower in Definite Plus (50%, n = 36), and lowest in Possible (0%, n = 18). Rates of psychiatric comorbidity, substance abuse, and toxicology findings for drugs of abuse were all higher in discordant cases than concordant cases. Possible SUDEP cases, an understudied group, were significantly older, and had higher rates of cardiac, drug, or toxicology findings than more certain SUDEP cases. With a potentially contributing or competing COD, ME/Cs favored non-epilepsy-related diagnoses, suggesting a bias toward listing CODs with structural or toxicological findings; SUDEP has no pathognomonic features. A history of epilepsy should always be listed on death certificates and autopsy reports. Even without an alternate COD, ME/Cs infrequently classified COD as "SUDEP." Improved collaboration and communication between epilepsy and ME/C communities improve diagnostic accuracy, as well as bereavement and research opportunities.
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Affiliation(s)
- Chloe Verducci
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, USA
| | - Daniel Friedman
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, USA
| | - Elizabeth J Donner
- Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Juliana Laze
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, USA
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14
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Affiliation(s)
- Orrin Devinsky
- Department of Neurology, NYU Grossman School of Medicine, NY, NY 10021
| | - Sanjay M Sisodiya
- Departments of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, WC1N 3BG, United Kingdom
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15
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Li J, Zhang X, Li N, Zhao D, Li G, Lin W. Mortality Rates in People With Convulsive Epilepsy in Rural Northeast China. Front Neurol 2020; 11:1013. [PMID: 33041973 PMCID: PMC7517037 DOI: 10.3389/fneur.2020.01013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 07/31/2020] [Indexed: 11/13/2022] Open
Abstract
Purpose: To examine the mortality rate and causes of death of phenobarbital (PB) monotherapy and sodium valproate (VPA) monotherapy in patients with convulsive epilepsy in rural northeast China and compare the differences in the results between the two antiepileptic drugs. Methods: Patients with convulsive epilepsy were recruited by trained public health workers in a project for epilepsy prevention and treatment. Patients were enrolled between January 2010 and December 2018 and were treated with PB or VPA. Mortality rate (MR), the proportional mortality ratio (PMR) for each cause, standardized mortality ratio, and years of potential life lost (YPLL) for sex, age, and cause were estimated based on the 2018 Chinese rural population. Results: A total of 3,916 patients with convulsive epilepsy enrolled in the study, of whom 3,418 received PB and 498 received VPA. There were 325 reported deaths (300 from the PB group) during the follow-up period. The MRs were 9.96 and 5.73% in the PB and VPA groups, respectively. The overall SMRs were 12.92 (95% confidence intervals [CI]: 11.50–13.93) and 7.39 (95% CI: 4.78–10.91), for the PB and VPA groups, respectively. Cerebrovascular disease and heart disease were the major causes of death in both treatment groups. The average YPLL for the PB group (21.9 years) was higher than that for the VPA group (13.4 years). Conclusion: This is the first epidemiological study to examine the MR of patients with epilepsy in rural northeast China. Our study is somewhat different from previous studies reported in China, and we provide new relevant data from northeast China.
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Affiliation(s)
- Jing Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xinyue Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Nan Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Danyang Zhao
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Guangjian Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Weihong Lin
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
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16
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Lhatoo SD, Bernasconi N, Blumcke I, Braun K, Buchhalter J, Denaxas S, Galanopoulou A, Josephson C, Kobow K, Lowenstein D, Ryvlin P, Schulze-Bonhage A, Sahoo SS, Thom M, Thurman D, Worrell G, Zhang GQ, Wiebe S. Big data in epilepsy: Clinical and research considerations. Report from the Epilepsy Big Data Task Force of the International League Against Epilepsy. Epilepsia 2020; 61:1869-1883. [PMID: 32767763 DOI: 10.1111/epi.16633] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/25/2022]
Abstract
Epilepsy is a heterogeneous condition with disparate etiologies and phenotypic and genotypic characteristics. Clinical and research aspects are accordingly varied, ranging from epidemiological to molecular, spanning clinical trials and outcomes, gene and drug discovery, imaging, electroencephalography, pathology, epilepsy surgery, digital technologies, and numerous others. Epilepsy data are collected in the terabytes and petabytes, pushing the limits of current capabilities. Modern computing firepower and advances in machine and deep learning, pioneered in other diseases, open up exciting possibilities for epilepsy too. However, without carefully designed approaches to acquiring, standardizing, curating, and making available such data, there is a risk of failure. Thus, careful construction of relevant ontologies, with intimate stakeholder inputs, provides the requisite scaffolding for more ambitious big data undertakings, such as an epilepsy data commons. In this review, we assess the clinical and research epilepsy landscapes in the big data arena, current challenges, and future directions, and make the case for a systematic approach to epilepsy big data.
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Affiliation(s)
- Samden D Lhatoo
- University of Texas Health Sciences Center at Houston, Houston, Texas
| | - Neda Bernasconi
- Neuroimaging of Epilepsy Laboratory, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| | - Ingmar Blumcke
- Friedrich-Alexander University Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Kees Braun
- Department of Child Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeffrey Buchhalter
- Department of Neurology, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
| | - Aristea Galanopoulou
- Saul Korey Department of Neurology, Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, Bronx, New York
| | - Colin Josephson
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Katja Kobow
- Friedrich-Alexander University Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Daniel Lowenstein
- Department of Neurology, University of California, San Francisco, San Francisco, California
| | - Philippe Ryvlin
- Department of Neurosciences, University of Lausanne, Lausanne, Switzerland
| | | | - Satya S Sahoo
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Maria Thom
- Institute of Neurology, University College London, London, UK
| | | | - Greg Worrell
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Guo-Qiang Zhang
- University of Texas Health Sciences Center at Houston, Houston, Texas
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
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17
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Natural history of generalized motor seizures: A retrospective analysis. Seizure 2020; 80:109-112. [PMID: 32563169 DOI: 10.1016/j.seizure.2020.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/07/2020] [Accepted: 05/22/2020] [Indexed: 12/23/2022] Open
Abstract
PURPOSE This study aims to characterize the natural history of generalized motor seizures through longitudinal stratification of patient-reported clinical seizures into high, medium and low rates of generalized motor seizures (also known as generalized tonic-clonic seizures or GTCs). METHODS From 2007 to 2018, 1.4 million seizures were recorded by 12,402 SeizureTracker.com users that met inclusion/exclusion criteria. The number of GTCs per year since the first seizure diary entry was calculated for each user and categorized as: Low (0 GTCs/year), Medium (1-2 GTCs/year), or High (>3 GTCs/year) GTC rates. RESULTS Kaplan-Meier survival curves for the time until exiting the initial category were computed. There was a global difference between risk groups (p < 0.01). Further pairwise log rank tests revealed a difference between each pair of risk groups (p < 0.01). At 3 years, 40.8% of people initially presenting with high GTC rates remained in their initial category, while 77.3% of people initially presenting with low GTC rates remained in their initial category. CONCLUSION A patient with a low rate of GTCs is likely to remain at low risk for future GTCs, whereas higher GTC rate patients (at least one GTC/year) may leave their initial risk stratification. Thus, yearly re-assessment may be prudent when considering risk of further GTCs. Given the association between higher yearly rates of GTCs with increased SUDEP risk and morbidity in epilepsy, further validation of these findings is important for prognostication.
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18
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Mehvari Habibabadi J, Moein H, Basiratnia R, Badihian S, Zaki B, Manouchehri N, Zare M, Barekatain M, Rahimian E, Mehvari Habibabadi A, Moein P, Aghakhani Y, Amina S, Lhatoo S. Outcome of lesional epilepsy surgery: Report of the first comprehensive epilepsy program in Iran. Neurol Clin Pract 2019; 9:286-295. [PMID: 31583181 DOI: 10.1212/cpj.0000000000000627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/14/2019] [Indexed: 11/15/2022]
Abstract
Background We investigated the utility of epilepsy surgery and postoperative outcome in patients with lesional epilepsy in Iran, a relatively resource-poor setting. Methods This prospective longitudinal study was conducted during 2007-2017 in Kashani Comprehensive Epilepsy Center, Isfahan, Iran. Patients with a diagnosis of intractable focal epilepsy, with MRI lesions, who underwent epilepsy surgery and were followed up ≥ 24 months, were included and evaluated for postoperative outcome. Results A total of 214 patients, with a mean age of 26.90 ± 9.82 years (59.8% men) were studied. Complex partial seizure was the most common type of seizure (85.9%), and 54.2% of the cases had auras. Temporal lobe lesions (75.2%) and mesial temporal sclerosis (48.1%) were the most frequent etiologies. With a mean follow-up of 62.17 ± 19.33 months, 81.8% of patients became seizure-free postoperatively. Anticonvulsants were reduced in 86% of the cases and discontinued in 40.7%. In keeping with previous studies, we found that seizure freedom rates were lower among patients with longer follow-up periods. Conclusions We found high rates of seizure freedom after surgery in lesional epilepsy patients despite limited facilities and infrastructure; antiepileptic medications were successfully tapered in almost half of the patients. Considering the favorable outcome of epilepsy surgery in our series, we believe that it is a major treatment option, even in less resource-intensive settings, and should be encouraged. Strategies to allow larger scale utility of epilepsy surgery in such settings in the developing world and dissemination of such knowledge may be considered an urgent clinical need, given the established mortality and morbidity in refractory epilepsy.
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Affiliation(s)
- Jafar Mehvari Habibabadi
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Houshang Moein
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Reza Basiratnia
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Shervin Badihian
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Bagher Zaki
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Navid Manouchehri
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Mohammad Zare
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Majid Barekatain
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Elham Rahimian
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Amirali Mehvari Habibabadi
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Payam Moein
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Yahya Aghakhani
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Shahram Amina
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Samden Lhatoo
- Kashani Comprehensive Epilepsy Center (JMH, MZ), Kashani Hospital, School of Medicine, Isfahan University of Medical Sciences; Departments of Neurology (JMH, SB, BZ, NM, MZ), Isfahan Neurosciences Research Center and Neurosurgery (HM), Department of Radiology (RB), Students' Research Center (SB, NM), and Department of Psychiatry (MB), Psychosomatic Research Center, School of Medicine, Isfahan University of Medical Sciences; Shefa Neuroscience Research Center (ER), Tehran, Iran; Students' Research Center (AMH), School of Medicine, Shahrekord University of Medical Sciences, Iran; Department of Neurology (PM), University of Tennessee Health Science Center, Memphis, TN; Department of Clinical Neurosciences (YA), University of Calgary, Calgary, Alberta, Canada; and Epilepsy Center (SA, SL), Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
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Wilson DA, Wannamaker BB, Malek AM, Selassie AW. Myocardial infarction after epilepsy onset: A population-based retrospective cohort study. Epilepsy Behav 2018; 88:181-188. [PMID: 30292053 DOI: 10.1016/j.yebeh.2018.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/23/2018] [Accepted: 09/09/2018] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Cardiovascular comorbidities of epilepsy such as hypertension, hyperlipidemia, and diabetes are associated with myocardial infarction (MI). Little data on the development of subsequent cardiovascular disease (CVD) in persons with epilepsy (PWE) are available, with inconsistent findings regarding the association between epilepsy and subsequent MI. A higher risk of MI among adults (without prior MI) following epilepsy diagnosis compared with that among controls was hypothesized. METHODS This retrospective cohort study used statewide hospital and emergency department (ED) encounter data from 2000-2013 for South Carolina residents aged >18 years without prior MI at the onset of epilepsy, or the first encounter for controls. Persons with epilepsy were compared with 1) persons with migraine (PWM), whose neurological condition has characteristics similar to epilepsy; and 2) persons with isolated lower extremity fracture (PWLF). Subsequent MI was defined as a diagnosis of MI after the first clinical encounter for epilepsy, migraine, or lower extremity fracture (LEF); the association was evaluated with Cox proportional hazard modeling methods. RESULTS In this study, 2.2% of PWE, 0.6% of PWM, and 1.2% of PWLF had a subsequent MI. Persons with epilepsy were significantly more likely to be non-Hispanic Black (NHB), be covered by Medicaid, and reside in a rural or low income area compared with PWM and PWLF. Specific cardiovascular disease risk factors were more prevalent in PWE than in PWM and PWLF. After adjustment, the hazard of subsequent MI in PWE was 48% higher than in PWM (hazard ratio (HR) = 1.48; 95% confidence intervals (CI) = 1.31-1.67) and 24% higher than in PWLF (HR = 1.24; 95% CI = 1.10-1.39). The hazard of MI increased with increasing age and number of additional comorbidities and was higher in males, those living in rural areas, and those with specific cardiovascular risk factors. CONCLUSION Persons with epilepsy had moderately elevated risk of subsequent MI compared with PWM or PWLF. The association between epilepsy and MI needs to be further investigated, and clinical care of PWE should include evaluation and management of risk factors for MI.
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Affiliation(s)
- Dulaney A Wilson
- Medical University of South Carolina, Department of Public Health Sciences, Charleston, SC, USA.
| | - Braxton B Wannamaker
- Medical University of South Carolina, Department of Neurology, Charleston, SC, USA.
| | - Angela M Malek
- Medical University of South Carolina, Department of Public Health Sciences, Charleston, SC, USA.
| | - Anbesaw W Selassie
- Medical University of South Carolina, Department of Public Health Sciences, Charleston, SC, USA.
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20
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Watila MM, Balarabe SA, Ojo O, Keezer MR, Sander JW. Overall and cause-specific premature mortality in epilepsy: A systematic review. Epilepsy Behav 2018; 87:213-225. [PMID: 30154056 DOI: 10.1016/j.yebeh.2018.07.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/12/2018] [Accepted: 07/22/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND We conducted a systematic review to ascertain the overall mortality and causes of premature mortality in epilepsy. METHODOLOGY We searched PubMed and Embase to identify relevant articles reporting mortality in epilepsy. An assessment of the methodological quality and overall quality of evidence of the identified studies was done using appropriate checklists. We extracted data from these studies reporting measures of overall and cause-specific mortality in epilepsy. RESULTS Sixty-three articles from fifty-six cohorts met the eligibility criteria, thirty-three population- or community-based and twenty-three hospital- or institutional-based studies. The majority of studies are from high-income countries (HIC). These studies reported overall excess mortality for people with epilepsy, with wide variability reported for population- or community-based studies and from low- and middle-income countries (LMIC). Twenty-seven articles from twenty-three cohorts reported measures of mortality for cause-specific mortality in epilepsy. People with epilepsy from HIC and LMIC have a higher risk of dying from various causes compared with the general population. Those in LMIC, however, have a particularly high chance of dying from external causes such as drowning and suicide. We observed a decrement over time in measures of overall and cause-specific mortality in cohorts. CONCLUSIONS Despite the heterogeneity in reports, our findings support the suggestions that people with epilepsy have an increased risk of premature mortality from various causes. Further work is needed to elucidate the mechanisms, to determine biomarkers for predicting those at risk, and to understand the implications of counseling and preventive strategies.
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Affiliation(s)
- Musa M Watila
- NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London WC1N 3BG, UK; Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, UK; Neurology Unit, Department of Medicine, University of Maiduguri Teaching Hospital, PMB 1414 Maiduguri, Borno State, Nigeria
| | - Salisu A Balarabe
- Neurology Unit, Department of Medicine, Usman Danfodiyo University Teaching Hospital, Sokoto, Sokoto State, Nigeria
| | - Olubamiwo Ojo
- Barking, Havering and Redbridge NHS Trust, London, UK
| | - Mark R Keezer
- Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, UK; Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec H2X 0C1, Canada; SEIN - Stichting Epilepsie Instellingen Nederland, Achterweg 5, 2103 SW Heemstede, Netherlands
| | - Josemir W Sander
- NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London WC1N 3BG, UK; Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, UK; SEIN - Stichting Epilepsie Instellingen Nederland, Achterweg 5, 2103 SW Heemstede, Netherlands.
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21
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Affiliation(s)
- Orrin Devinsky
- Department of Neurology, NYU Langone Medical Center, New York, New York
| | - Anuradha Singh
- Department of Neurology, NYU Langone Medical Center, New York, New York
| | - Daniel Friedman
- Department of Neurology, NYU Langone Medical Center, New York, New York
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22
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Trinka E, Kwan P, Lee B, Dash A. Epilepsy in Asia: Disease burden, management barriers, and challenges. Epilepsia 2018; 60 Suppl 1:7-21. [PMID: 29953579 DOI: 10.1111/epi.14458] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2017] [Indexed: 12/26/2022]
Abstract
This article reviews the burden of epilepsy in Asia, the challenges faced by people with epilepsy, and the management of epilepsy. Comparison is made with other parts of the world. For this narrative review, data were collected using specified search criteria. Articles investigating the epidemiology of epilepsy, diagnosis, comorbidities and associated mortality, stigmatization, and treatment were included. Epilepsy is a global health care issue affecting up to 70 million people worldwide. Nearly 80% of people with epilepsy live in low- and middle-income countries with limited resources. People with epilepsy are prone to physical and psychological comorbidities, including anxiety and depression, which can negatively impact their quality of life. Furthermore, people with epilepsy are at higher risk of premature death than people without epilepsy. Discrimination or stigmatization of people with epilepsy is common in Asia and can affect their education, work, and marriage opportunities. Access to epilepsy treatment varies throughout Asia. Although highly advanced treatment is available in some countries, up to 90% of people with epilepsy are not adequately treated or are not treated with conventional antiepileptic therapy in resource-limited countries. People in remote areas often do not receive any epilepsy care. First-generation antiepileptic drugs (AEDs) are available, but usually only in urban areas, and second-generation AEDs are not available in all countries. Newer AEDs tend to have more favorable safety profiles than first-generation AEDs and provide options to tailor therapy for individual patients, especially those with comorbidities. Active epilepsy surgery centers are present in some countries, although epilepsy surgery is often underutilized given the number of patients who could benefit. Further epidemiologic research is needed to provide accurate epilepsy data across the Asian region. Coordinated action is warranted to improve access to treatment and care.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, University Hospital Paracelsus Medical University, Salzburg, Austria.,Institute of Public Health, Medical Decision Making, and Health Technology Assessment, University for Health Sciences, Medical Informatics, and Technology, Hall in Tyrol, Austria
| | - Patrick Kwan
- Departments of Medicine and Neurology, University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - ByungIn Lee
- Department of Neurology, Inje University School of Medicine, Haeundae Paik Hospital, Busan, South Korea
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Middleton OL, Atherton DS, Bundock EA, Donner E, Friedman D, Hesdorffer DC, Jarrell HS, McCrillis AM, Mena OJ, Morey M, Thurman DJ, Tian N, Tomson T, Tseng ZH, White S, Wright C, Devinsky O. National Association of Medical Examiners Position Paper: Recommendations for the Investigation and Certification of Deaths in People with Epilepsy. Acad Forensic Pathol 2018; 8:119-135. [PMID: 31240030 PMCID: PMC6474453 DOI: 10.23907/2018.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Sudden unexpected death of an individual with epilepsy (SUDEP) can pose a challenge to death investigators, as most deaths are unwitnessed and the individual is commonly found dead in bed. Anatomic findings (e.g., tongue/lip bite) are commonly absent and of varying specificity, limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus, it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden, unexpected death in a person with epilepsy is encountered.
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Affiliation(s)
| | - Daniel S. Atherton
- University of Alabama at Birmingham, Anatomic Pathology, Division of Forensic Pathology
| | | | - Elizabeth Donner
- Comprehensive Epilepsy Program, The Hospital for Sick Children - Toronto
| | | | | | - Heather S. Jarrell
- University of New Mexico Health Sciences Center, Office of the Medical Investigator
| | | | | | | | | | - Niu Tian
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, Epilepsy Program
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, Department of Neurology, Karolinska University Hospital
| | - Zian H. Tseng
- University of California, San Francisco, Cardiac Electrophysiology Section, Cardiology Division
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Middleton O, Atherton D, Bundock E, Donner E, Friedman D, Hesdorffer D, Jarrell H, McCrillis A, Mena OJ, Morey M, Thurman D, Tian N, Tomson T, Tseng Z, White S, Wright C, Devinsky O. National Association of Medical Examiners position paper: Recommendations for the investigation and certification of deaths in people with epilepsy. Epilepsia 2018; 59:530-543. [PMID: 29492970 PMCID: PMC6084455 DOI: 10.1111/epi.14030] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 11/27/2022]
Abstract
Sudden unexpected death of an individual with epilepsy can pose a challenge to death investigators, as most deaths are unwitnessed, and the individual is commonly found dead in bed. Anatomic findings (eg, tongue/lip bite) are commonly absent and of varying specificity, thereby limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention constituted an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden unexpected death in a person with epilepsy is encountered.
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Affiliation(s)
- Owen Middleton
- Hennepin County Medical Examiner’s Office, Minneapolis, MN, USA
| | - Daniel Atherton
- Anatomic Pathology, Division of Forensic Pathology, Cooper Green Hospital, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Elizabeth Donner
- Comprehensive Epilepsy Program, Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Daniel Friedman
- Department of Neurology, Langone Comprehensive Epilepsy Center, New York University, New York, NY, USA
| | - Dale Hesdorffer
- Gertrude H Sergievsky Center and Department of Epidemiology, Columbia University, New York, NY, USA
| | - Heather Jarrell
- Office of the Medical Investigator, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Aileen McCrillis
- New York University Langone Health, New York University School of Medicine, New York, NY, USA
| | - Othon J. Mena
- Ventura County Office of Chief Medical Examiner, Ventura, CA, USA
| | - Mitchel Morey
- Hennepin County Medical Examiner’s Office, Minneapolis, MN, USA
| | - David Thurman
- Department of Neurology, School of Medicine, Emory University, Atlanta, GA, USA
| | - Niu Tian
- Division of Population Health, Epilepsy Program, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, USA
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Zian Tseng
- Cardiac Electrophysiology Section, Cardiology Division, University of California, San Francisco, San Francisco, CA, USA
| | - Steven White
- Office of the Medical Examiner, Cook County, Chicago, IL, USA
| | | | - Orrin Devinsky
- Department of Neurology, Langone Comprehensive Epilepsy Center, New York University, New York, NY, USA
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Shi J, Lacuey N, Lhatoo S. Surgical outcome of MRI-negative refractory extratemporal lobe epilepsy. Epilepsy Res 2017; 133:103-108. [PMID: 28477458 DOI: 10.1016/j.eplepsyres.2017.04.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 04/05/2017] [Accepted: 04/14/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study is to determine outcome of resective epilepsy surgery in MRI-negative extratemporal lobe epilepsy (MNETLE) patients who underwent invasive evaluations and to determine factors governing outcome. METHODS We studied 28 patients who underwent resective epilepsy surgery for MNETLE from August 2006 to November 2015, in whom complete follow-up information was available. Electro-clinical, pathological and surgical data were evaluated. 24 patients (82.8%) were explored with intracranial EEG (9 stereoelectroencephalography (SEEG), 7 subdural grids and 8 both). All patients were followed for at least 6 months. RESULTS During a mean follow up period of 32 [6-113] months, 13 (46.4%) patients became seizure-free (ILAE 1) and 18 (64.3%) had a good (ILAE 1, 2, 3) outcome. 21 (75.0%) patients had focal cortical dysplasia (FCD). Univariate analysis showed that more restricted (regional) interictal and ictal epileptiform discharges in surface EEG were significantly associated with seizure freedom (P=0.016 and P=0.024). Multivariate analysis confirmed that having ≥120 electrode contacts in the evaluation is an independent variable predicting seizure freedom (HR=4.283, 95% CI=1.342-13.676, P=0.014). CONCLUSION Invasive EEG is a powerful tool in the pre-surgical evaluation of patients with MNETLE. Invasive EEG implantation that include the irritative zone and EEG onset zone as indicated by surface EEG, as well as wider brain coverage predict seizure freedom, contingent upon a sound anatomo-electro-clinical hypothesis for implantation.
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Affiliation(s)
- Jianguo Shi
- Department of Neurosurgery, Jinan Central Hospital affiliated to Shandong University, Jinan, Shandong, 250000, China.
| | - Nuria Lacuey
- Epilepsy Center, UH Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Samden Lhatoo
- Epilepsy Center, UH Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
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26
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Shmuely S, Sisodiya SM, Gunning WB, Sander JW, Thijs RD. Mortality in Dravet syndrome: A review. Epilepsy Behav 2016; 64:69-74. [PMID: 27732919 DOI: 10.1016/j.yebeh.2016.09.007] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 09/05/2016] [Accepted: 09/05/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Premature mortality is a major issue in Dravet syndrome (DS). To improve understanding of DS premature mortality, we conducted a comprehensive literature search with a particular emphasis on SUDEP. METHODS We searched PubMed, Embase, Web of Science, Cochrane, CENTRAL, CINAHL, PsycINFO, Academic Search Premier, and ScienceDirect on the following terms: "Dravet syndrome", "severe myoclonic epilepsy", "SMEI", "mortality", "survivors", "prognosis", and "death". DS cases or cohorts studies reporting mortality were included. RESULTS The search yielded 676 articles and 86 meeting abstracts. After removing duplicates and screening titles and abstracts, full text of 73 articles was reviewed. Only 28 articles and six meeting abstracts met inclusion criteria. Five articles and four meeting abstracts were excluded, as the case(s) were also described elsewhere. After checking the references, five additional studies were included. The 30 items reported 177 unique cases. Sudden unexpected death in epilepsy was the likely cause in nearly half of the cases (n=87, 49%), followed by status epilepticus (n=56, 32%). Drowning or accidental death was reported in 14 cases (8%), infections in 9 (5%), other causes in six (3%), and unknown in five (3%). Age at death was reported for 142 of the 177 cases (80%), with a mean age of 8.7±9.8years (SD); 73% died before the age of 10years. DISCUSSION Dravet syndrome is characterized by high epilepsy-related premature mortality and a marked young age at death. Sudden unexpected death in epilepsy is the leading reported cause of death in DS, accounting for nearly half of all deaths. The cause of this excess mortality remains elusive but may be explained by epilepsy severity, as well as genetic susceptibility to SUDEP.
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Affiliation(s)
- Sharon Shmuely
- Stichting Epilepsie Instellingen Nederland - SEIN, Heemstede & Zwolle, The Netherlands; NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK; Epilepsy Society, Bucks SL9 0RJ, UK
| | - Sanjay M Sisodiya
- NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK; Epilepsy Society, Bucks SL9 0RJ, UK
| | - W Boudewijn Gunning
- Stichting Epilepsie Instellingen Nederland - SEIN, Heemstede & Zwolle, The Netherlands; Department of Genetics, Centre for Molecular Medicine, University Medical Centre Utrecht, The Netherlands
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland - SEIN, Heemstede & Zwolle, The Netherlands; NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK; Epilepsy Society, Bucks SL9 0RJ, UK
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland - SEIN, Heemstede & Zwolle, The Netherlands; NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK; Epilepsy Society, Bucks SL9 0RJ, UK; Department of Neurology, LUMC Leiden University Medical Centre, Leiden, The Netherlands.
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27
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Devinsky O, Hesdorffer DC, Thurman DJ, Lhatoo S, Richerson G. Sudden unexpected death in epilepsy: epidemiology, mechanisms, and prevention. Lancet Neurol 2016; 15:1075-88. [DOI: 10.1016/s1474-4422(16)30158-2] [Citation(s) in RCA: 369] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/29/2016] [Accepted: 06/29/2016] [Indexed: 12/24/2022]
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Goldman AM, LaFrance WC, Benke T, Asato M, Drane D, Pack A, Syed T, Doss R, Lhatoo S, Fureman B, Dingledine R. 2014 Epilepsy Benchmarks Area IV: Limit or Prevent Adverse Consequence of Seizures and Their Treatment Across The Lifespan. Epilepsy Curr 2016; 16:198-205. [PMID: 27330453 PMCID: PMC4913859 DOI: 10.5698/1535-7511-16.3.198] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Alica M. Goldman
- Associate Professor, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, NB222, Houston, TX, USA
| | - W. Curt LaFrance
- Associate Professor, Departments of Neurology and Psychiatry, Alpert Medical School, Brown University, Providence RI 02903-4923 USA
| | - Tim Benke
- Associate Professor, Departments of Pediatrics, Neurology, Pharmacology and Otolaryngology, University of Colorado School of Medicine, Aurora, CO
| | - Miya Asato
- Associate Professor, Pediatrics and Psychiatry, Divisionof Child Neurology, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Dan Drane
- Assistant Professor, Departments of Neurology and Pediatrics, Emory University School of Medicine and Department of Neurology, University of Washington School of Medicine
| | - Alison Pack
- Associate Professor of Neurology, Department of Neurology, Columbia University Medical Center, New York, NY
| | - Tanvir Syed
- Assistant Professor of Neurology, University Hospitals Case Medical Center, Cleveland, OH
| | - Robert Doss
- Clinical Neuropsychologist, Minnesota Epilepsy Group, P.A., St. Paul, MN and Department of Neurology, University of Minnesota-Twin Cities, MN
| | - Samden Lhatoo
- Professor and Chair, Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Brandy Fureman
- Program Director, Channels Synapses and Circuits Cluster, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Ray Dingledine
- Professor and Chair, Department of Pharmacology, Emory University, Atlanta GA
| | - for the American Epilepsy Society (AES)/National Institute of Neurological Disorders and Stroke (NINDS) Epilepsy Benchmark Stewards.
- Associate Professor, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, NB222, Houston, TX, USA
- Associate Professor, Departments of Neurology and Psychiatry, Alpert Medical School, Brown University, Providence RI 02903-4923 USA
- Associate Professor, Departments of Pediatrics, Neurology, Pharmacology and Otolaryngology, University of Colorado School of Medicine, Aurora, CO
- Associate Professor, Pediatrics and Psychiatry, Divisionof Child Neurology, Children's Hospital of Pittsburgh, Pittsburgh, PA
- Assistant Professor, Departments of Neurology and Pediatrics, Emory University School of Medicine and Department of Neurology, University of Washington School of Medicine
- Associate Professor of Neurology, Department of Neurology, Columbia University Medical Center, New York, NY
- Assistant Professor of Neurology, University Hospitals Case Medical Center, Cleveland, OH
- Clinical Neuropsychologist, Minnesota Epilepsy Group, P.A., St. Paul, MN and Department of Neurology, University of Minnesota-Twin Cities, MN
- Professor and Chair, Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH
- Program Director, Channels Synapses and Circuits Cluster, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
- Professor and Chair, Department of Pharmacology, Emory University, Atlanta GA
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Wilson DA, Malek AM, Wagner JL, Wannamaker BB, Selassie AW. Mortality in people with epilepsy: A statewide retrospective cohort study. Epilepsy Res 2016; 122:7-14. [DOI: 10.1016/j.eplepsyres.2016.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 01/18/2016] [Accepted: 01/28/2016] [Indexed: 10/22/2022]
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Devinsky O, Spruill T, Thurman D, Friedman D. Recognizing and preventing epilepsy-related mortality: A call for action. Neurology 2015; 86:779-86. [PMID: 26674330 PMCID: PMC4763802 DOI: 10.1212/wnl.0000000000002253] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 10/29/2015] [Indexed: 11/22/2022] Open
Abstract
Epilepsy is associated with a high rate of premature mortality from direct and indirect effects of seizures, epilepsy, and antiseizure therapies. Sudden unexpected death in epilepsy (SUDEP) is the second leading neurologic cause of total lost potential life-years after stroke, yet SUDEP may account for less than half of all epilepsy-related deaths. Some epilepsy groups are especially vulnerable: individuals from low socioeconomic status groups and those with comorbid psychiatric illness die more often than controls. Despite clear evidence of an important public health problem, efforts to assess and prevent epilepsy-related deaths remain inadequate. We discuss factors contributing to the underestimation of SUDEP and other epilepsy-related causes of death. We suggest the need for a systematic classification of deaths directly due to epilepsy (e.g., SUDEP, drowning), due to acute symptomatic seizures, and indirectly due to epilepsy (e.g., suicide, chronic effects of antiseizure medications). Accurately estimating the frequency of epilepsy-related mortality is essential to support the development and assessment of preventive interventions. We propose that educational interventions and public health campaigns targeting medication adherence, psychiatric comorbidity, and other modifiable risk factors may reduce epilepsy-related mortality. Educational campaigns regarding sudden infant death syndrome and fires, which kill far fewer Americans than epilepsy, have been widely implemented. We have done too little to prevent epilepsy-related deaths. Everyone with epilepsy and everyone who treats people with epilepsy need to know that controlling seizures will save lives.
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Affiliation(s)
- Orrin Devinsky
- From the Departments of Neurology (O.D., D.F.) and Population Health (T.S.), New York University School of Medicine, New York; and the Department of Neurology (D.T.), Emory University School of Medicine, Atlanta, GA.
| | - Tanya Spruill
- From the Departments of Neurology (O.D., D.F.) and Population Health (T.S.), New York University School of Medicine, New York; and the Department of Neurology (D.T.), Emory University School of Medicine, Atlanta, GA
| | - David Thurman
- From the Departments of Neurology (O.D., D.F.) and Population Health (T.S.), New York University School of Medicine, New York; and the Department of Neurology (D.T.), Emory University School of Medicine, Atlanta, GA
| | - Daniel Friedman
- From the Departments of Neurology (O.D., D.F.) and Population Health (T.S.), New York University School of Medicine, New York; and the Department of Neurology (D.T.), Emory University School of Medicine, Atlanta, GA
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Nevalainen O, Simola M, Ansakorpi H, Raitanen J, Artama M, Isojärvi J, Auvinen A. Epilepsy, excess deaths and years of life lost from external causes. Eur J Epidemiol 2015; 31:445-53. [DOI: 10.1007/s10654-015-0095-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 10/22/2015] [Indexed: 11/30/2022]
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