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Li CJ, Hou JC, Chou CC, Shih YC, Dufau S, Lin PT, McGonigal A, Yu HY. Face swapping in seizure videos for patient deidentification. Epilepsy Res 2024; 207:107453. [PMID: 39321717 DOI: 10.1016/j.eplepsyres.2024.107453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 09/10/2024] [Accepted: 09/17/2024] [Indexed: 09/27/2024]
Abstract
OBJECTIVE This study aimed to test different AI-based face-swapping models applied to videos of epileptic seizures, with the goal of protecting patient privacy while retaining clinically useful seizure semiology. We hypothesized that specific models would show differences in semiologic fidelity compared to the original clinical videos. METHODS Three open-source models, SimSwap, MobileFaceSwap and GHOST were adopted for face-swapping. For every model, an AI generated male and female image were used to replace the original faces. One representative seizure per patient from three patients with epilepsy was chosen (3 seizure videos x 3 AI models x 2 M/F swap) and remade to 18 transformed video clips. To evaluate the performance of the three models, we used both objective (AI-based) and subjective (expert clinician) evaluation. The objective assessment included four metrics for facial appearance and four metrics for facial expression changes. Four experienced epileptologists reviewed the clips and scoring according to deidentification and preservation of semiology. Kruskal-Wallis H test was used for statistical analysis among the models. RESULTS In the reproduced videos, the swapped face cannot be recognized as the original face, with no significant difference in scores of deidentification either by objective or subjective assessment. Regarding semiology preservation, no significant differences between models were observed in the objective evaluations. The subjective evaluations revealed that the GHOST model outperformed the other two models (p=0.028). CONCLUSION This is the first study evaluating AI face swapping models in epileptic seizure video clips. Optimization of AI face-swapping models could enhance the accessibility of seizure videos for education and research while protecting patient privacy and maintaining semiology.
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Affiliation(s)
- Chin-Jou Li
- Department of Computer Science and Information Engineering, National Taiwan University, Taiwan
| | - Jen-Cheng Hou
- Research Center for Information Technology Innovation, Academia Sinica, Taiwan
| | - Chien-Chen Chou
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan; College of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taiwan
| | - Yen-Cheng Shih
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan; College of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taiwan
| | - Stephane Dufau
- Laboratoire de psychologie cognitive (UMR7290), CNRS & Aix-Marseille University, France; Queensland Brain Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Po-Tso Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan; College of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taiwan
| | - Aileen McGonigal
- Queensland Brain Institute, The University of Queensland, Brisbane, Queensland, Australia; Department of Neurosciences, Mater Misericordiae Hospital, Brisbane, Queensland, Australia; Mater Research Institute, Faculty of Medicine, University of Queensland, Australia
| | - Hsiang-Yu Yu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan; College of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, Taiwan.
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2
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Cengiz O, Jungilligens J, Michaelis R, Wellmer J, Popkirov S. Dissociative seizures in the emergency room: room for improvement. J Neurol Neurosurg Psychiatry 2024; 95:294-299. [PMID: 37758452 PMCID: PMC10958294 DOI: 10.1136/jnnp-2023-332063] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/07/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Dissociative seizures, also known as functional or psychogenic non-epileptic seizures, account for 11%-27% of all emergency seizure presentations. Misdiagnosis as epileptic seizures is common and leads to ineffective and potentially harmful treatment escalations. We assess the potential for diagnostic improvement at different stages of emergency workup and estimate the utility of benzodiazepines. METHODS A retrospective study of all emergency presentations with a discharge diagnosis of acute dissociative seizures seen at a university hospital 2010-2022 was performed to assess clinical characteristics and emergency decision-making. RESULTS Among 156 patients (73% female, median 29 years), 15% presented more than once for a total of 203 presentations. Half of seizures were ongoing at first medical contact; prolonged seizures and clusters were common (23% and 24%). Diagnostic accuracy differed between on-site emergency physicians and emergency department neurologists (12% vs 52%). Typical features such as eye closure, discontinuous course and asynchronous movements were common. Benzodiazepines were given in two-thirds of ongoing seizures, often in high doses and preferentially for major hyperkinetic semiology. Clinical response to benzodiazepines was mixed, with a minority of patients remaining either unaffected (16%) or becoming critically sedated (13%). A quarter of patients given benzodiazepines by emergency medical services were admitted to a monitoring unit, 9% were intubated. CONCLUSIONS Improved semiological assessment could reduce early misdiagnosis of dissociative seizures. Although some seizures seem to respond to benzodiazepines, critical sedation is common, and further studies are needed to assess the therapeutic ratio.
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Affiliation(s)
- Ozan Cengiz
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Rosa Michaelis
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
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Talai A, Freedman DA, Albert DVF. Education Research: Educating Child Neurology Residents About Psychogenic Nonepileptic Seizures: A Needs Assessment. NEUROLOGY. EDUCATION 2024; 3:e200111. [PMID: 39360154 PMCID: PMC11441745 DOI: 10.1212/ne9.0000000000200111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/15/2023] [Indexed: 10/04/2024]
Abstract
Background and Objectives Psychogenic nonepileptic seizures (PNES) are difficult to differentiate from epileptic seizures (ES) even for neurologists who see these conditions frequently. This difficulty is due to overlapping semiologic findings between the 2 diagnoses. Previous studies have shown that trainees, including neurology trainees, are not accurate in differentiating PNES from ES. Neurologists often find the communication of PNES difficult. Despite these challenges, most programs do not have formal curricula for teaching PNES, and there are no standards for residency curricula in this topic. The aim of this study was to understand the gaps in resident education on PNES. Methods This study was accomplished through a needs assessment of current pediatric neurology residents and residency program directors (PDs). Two unique surveys were distributed, 1 for child neurology trainees and 1 for PDs. Questions were designed to understand trainees' self-reported knowledge, confidence, current education received, and desired teaching. Similarly for PDs, questions were designed to assess the state of education on PNES at their programs, sufficiency of education, and their desire for standardized curriculum. Results Sixty-eight trainees and 21 PDs responded to the survey. Approximately one-quarter of trainees reported neutral to low levels of confidence and 38% reported neutral to low levels of knowledge in caring for patients with PNES. Trainees reported that directing patients with PNES to appropriate management was the most challenging aspect of care, followed by communicating the diagnosis, with 60% and 46% reporting difficulty, respectively. Only 21% of residents felt their current PNES education needs no improvement. One-fifth of PDs felt their current PNES education is not sufficient, and all reported they would incorporate a standardized curriculum. Trainees reported preferring to learn about this topic through lectures and simulation, while PDs preferred online modules and simulation. Discussion While residents and PDs report high confidence and knowledge in treating pediatric patients with PNES, respondents felt improvement is needed to their curricula regarding this topic. Multiple learning methods are preferred, with emphasis on communicating the diagnosis and management of patients once the diagnosis has been made. PDs desire a standardized curriculum and would incorporate one into their programs. Findings of this study could be used to create a national curriculum.
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Affiliation(s)
- Afsaneh Talai
- From the Division of Pediatric Neurology (A.T.), Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas and Children's Medical Center of Dallas; Department of Neurology (D.A.F.), Dell Medical School, Austin, TX; and Division of Child Neurology (D.V.F.A.), Nationwide Children's Hospital, Columbus, OH
| | - Daniel A Freedman
- From the Division of Pediatric Neurology (A.T.), Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas and Children's Medical Center of Dallas; Department of Neurology (D.A.F.), Dell Medical School, Austin, TX; and Division of Child Neurology (D.V.F.A.), Nationwide Children's Hospital, Columbus, OH
| | - Dara V F Albert
- From the Division of Pediatric Neurology (A.T.), Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas and Children's Medical Center of Dallas; Department of Neurology (D.A.F.), Dell Medical School, Austin, TX; and Division of Child Neurology (D.V.F.A.), Nationwide Children's Hospital, Columbus, OH
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Wardrope A. The promises and pitfalls of seizure phenomenology. Seizure 2023; 113:48-53. [PMID: 37976801 DOI: 10.1016/j.seizure.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/11/2023] [Indexed: 11/19/2023] Open
Abstract
The typical adult patient presenting with a first seizure has a normal clinical examination, uninformative investigations, and often has no witness to their episode. The assessing clinician, therefore, has one primary source of information to guide their assessment; the patient's experience. However, seizure phenomenology - the subjective seizure experience - has received relatively less attention by researchers than objective semiology or investigations. This essay reviews the clinical importance of seizure phenomenology, and the challenges clinicians face in eliciting accurate and clinically relevant descriptions of ictal experience. I conclude by discussing tools that clinicians may use to support the clinical application of seizure phenomenology, and exploring the subjectivity of epilepsy more broadly.
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Affiliation(s)
- Alistair Wardrope
- Academic Neurology Unit, The University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, United Kingdom; Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, United Kingdom.
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Lemus HN, Sarkis RA. Epilepsy care in nursing facilities: Knowledge gaps and opportunities. Epilepsy Behav 2023; 138:108997. [PMID: 36442262 DOI: 10.1016/j.yebeh.2022.108997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
Epilepsy in the elderly is a complex disease, often underdiagnosed, and inadequately treated. It requires a multi-disciplinary approach and care coordination especially if the patient resides in a nursing facility. Episodes of loss of consciousness falls, or amnestic events in those living in a nursing facility require a detailed description and an urgent assessment to rule out an epileptic seizure. Prompt recognition of seizures and the implementation of treatment protocols in those with recurrent seizures are needed to prevent unnecessary emergency visits. Although there is a myriad of antiseizure medications (ASM) to treat seizures, clinicians should be aware of common interactions, side effects, and changes in pharmacodynamics with age. There is a limited number of ASMs that have been properly studied in clinical trials to assess tolerability and efficacy in the elderly, and an over-reliance on enzyme-inducing ASMs. Strategies to improve the knowledge of health care providers include electronic resources, treatment protocols, and improving awareness of the efficacy, drug-drug interaction, and short-term and long-term monitoring of ASM side effects.
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Affiliation(s)
| | - Rani A Sarkis
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
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6
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Saker TS, Katson M, Herskovitz SE, Herskovitz M. Knowledge and emotional attitudes of health care practitioners regarding patients with psychogenic nonepileptic seizures. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1097-1103. [PMID: 36577408 PMCID: PMC9797271 DOI: 10.1055/s-0042-1758646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Psychogenic nonepileptic seizures (PNESs) are paroxysmal events that resemble epileptic seizures without concomitant changes in electroencephalograms (EEGs) or any other physiological cause. These seizures are one of the most common and dramatic conversion disorders. First responders treat many PNES patients with unnecessary emergency abortive medication and sometimes even intubate them. Several of our PNES patients have complained they have experienced harsh attitudes from health care practitioners (HCPs), especially during their stay in the emergency room (ER). OBJECTIVE To assess the emotional attitude of HCPs toward PNES patients. METHODS We handed a questionnaire containing 23 questions regarding PNES patients to HCPs from emergency medicine, internal medicine, and neurology disciplines. The questions dealt with three categories: diagnosis, management, and emotional attitudes. RESULTS Overall, 47 HCPs participated in this study: 11 ER, 18 internal medicine, and 18 neurology practitioners. The HCP from those disciplines showed high knowledge and good management practice of PNES patients. On the other hand, the HCPs agreed with most emotional attitude statements regarding PNES patients, reflecting a high percentage of negative emotional attitudes toward this group of patients. We did not find any correlation between negative emotional attitude and HCP department, profession, or seniority. CONCLUSIONS Although HCPs in our center perform good management practice regarding PNES patients, most reported a negative emotional attitude. This finding implies that what PNES patients feel regarding the harsh attitudes is also reflected by HCP views. Emotional attitudes towards PNES patients may not depend solely on the level of knowledge of the HCPs.
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Affiliation(s)
| | - Mark Katson
- Rambam Health Care Center, Neurology Department, Haifa, Israel.
| | | | - Moshe Herskovitz
- Rambam Health Care Center, Neurology Department, Haifa, Israel.,Technion Institute of Technology, Faculty of Medicine, Haifa, Israel.,Address for correspondence Moshe Herskovitz
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Grönheit W, Behrens V, Liakina T, Kellinghaus C, Noachtar S, Popkirov S, Wehner T, Brammen E, Wellmer J. Teaching distinguishing semiological features improves diagnostic accuracy of seizure-like events by emergency physicians. Neurol Res Pract 2022; 4:56. [DOI: 10.1186/s42466-022-00220-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 10/13/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Misdiagnosis of seizure-like events (SLE) in emergency situations is common. Here, we evaluate whether a single, video-based lesson highlighting distinguishing semiological features can improve the diagnostic accuracy of emergency physicians for epileptic seizures (ES), psychogenic non-epileptic seizures (PNES) and syncopes (SY).
Methods
40 emergency physicians (24 anesthetists, nine surgeons and seven internal medicine specialists by primary specialty) participated in a prospective trial on the diagnostic accuracy of SLE. They assessed video-displayed SLE at two time points: before and after a lecture on distinguishing semiological features. In the lecture, semiological features were demonstrated using patient videos, some were acted by the instructor in addition. The increase in correct diagnoses and recognition of distinguishing semiological features were analyzed.
Results
Before the lesson, 45% of 200 SLE-ratings were correct: 15% of SY (n = 40), 30% of PNES (n = 40), 59% of ES (n = 120, focal to bilateral tonic–clonic seizures (FBTCS) 87.5% (n = 40), focal impaired aware seizures (FIAS) 45% (n = 80)). Semiology teaching increased both the rate of correct diagnoses of SLE to overall 79% (p < 0.001) (ES 91% (p < 0.001), FBCTS 98% (n.s.), FIAS 88% (p < 0.001), PNES 88% (p < 0.001), SY 35% (p < 0.001)), and the number of recognized distinguishing semiological features. We identified several semiological features with high entity specific positive predictive values (> 0.8).
Conclusions
A single 45-min video-based lesson highlighting distinguishing semiological features improves the diagnostic accuracy of ES, PNES and SY by emergency physicians. We expect that including this aspect into the curriculum of emergency physicians will lead to better individual patient treatment in pre-hospital medicine and more appropriate subsequent use of clinical resources.
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Zhang J, Chatzichristos C, Vandecasteele K, Swinnen L, Broux V, Cleeren E, Van Paesschen W, De Vos M. Automatic annotation correction for wearable EEG based epileptic seizure detection. J Neural Eng 2022; 19. [PMID: 35158349 DOI: 10.1088/1741-2552/ac54c1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/14/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Video-electroencephalography (vEEG), which defines the ground truth for the detection of epileptic seizures, is inadequate for long-term home monitoring. Thanks to their advantages in comfort and unobtrusiveness, wearable EEG devices have been suggested as a solution for home monitoring. However, one of the challenges in data-driven automated seizure detection with wearable EEG data is to have reliable seizure annotations. Seizure annotations on the gold-standard 25-channel vEEG recordings may not be optimal to delineate seizure activity on the concomitantly recorded wearable EEG, due to artifacts or absence of ictal activity on the limited set of electrodes of the wearable EEG. This paper aims to develop an automatic approach to correct the imperfect annotations of seizure activity on wearable EEG, which can be used to train seizure detection algorithms. APPROACH This paper first investigates the effectiveness of correcting the seizure annotations for the training set with a visual annotation correction. Then a novel approach has been proposed to automatically remove non-seizure data from wearable EEG in epochs annotated as seizures in gold-standard video-EEG recordings. The performance of the automatic annotation correction approach was evaluated by comparing the seizure detection models trained with 1. original vEEG seizure annotations, 2. visually corrected seizure annotations, and 3. automatically corrected seizure annotations. RESULTS The automatic seizure detection approach trained with automatically corrected seizure annotations was more sensitive and had fewer false-positive detections compared to the approach trained with visually corrected seizure annotations, and the approach trained with the original seizure annotations from gold-standard vEEG. SIGNIFICANCE The wearable EEG seizure detection approach performs better when trained with automatic seizure annotation correction.
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Affiliation(s)
- Jingwei Zhang
- Department of Electrical Engineering, STADIUS, KU Leuven, Kasteelpark Arenberg 10, Leuven, Flanders, 3000, BELGIUM
| | - Christos Chatzichristos
- Department of Electrical Engineering, STADIUS, KU Leuven, Kasteelpark Arenberg 10 - box 2446, Leuven, Flanders, 3000, BELGIUM
| | - Kaat Vandecasteele
- Department of Electrical Engineering, STADIUS, KU Leuven, Kasteelpark Arenberg 10, Leuven, Flanders, 3000, BELGIUM
| | - Lauren Swinnen
- KU Leuven, ON V Herestraat 49 - box 1022, Leuven, Flanders, 3000, BELGIUM
| | - Victoria Broux
- Katholieke Universiteit Leuven UZ Leuven, UZ Herestraat 49, Leuven, Flanders, 3000, BELGIUM
| | - Evy Cleeren
- Katholieke Universiteit Leuven UZ Leuven, ON II Herestraat 49 - box 1021, Leuven, Flanders, 3000, BELGIUM
| | - Wim Van Paesschen
- Katholieke Universiteit Leuven UZ Leuven, UZ Herestraat 49 - box 7003, Leuven, Flanders, 3000, BELGIUM
| | - Maarten De Vos
- Department of Electrical Engineering, KU Leuven, Kasteelpark Arenberg 10 - box 2440, Leuven, Flanders, 3000, BELGIUM
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Birca V, Keezer MR, Chamelian L, Lortie A, Nguyen DK. Recognition of Psychogenic Versus Epileptic Seizures Based on Videos. Can J Neurol Sci 2021; 49:1-9. [PMID: 34663489 DOI: 10.1017/cjn.2021.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Ictal semiology interpretation for differentiating psychogenic nonepileptic seizures (PNESs) and epileptic seizures (ESs) is important for the institution of appropriate treatment. Our objective was to assess the ability of different health care professionals (HCPs) or students to distinguish PNES from ES based on video-recorded seizure semiology. METHODS This study was designed following the Standards for Reporting of Diagnostic Accuracy Studies (STARD) guidelines. We showed in a random mix 36 videos of PNES or ES (18 each) and asked 558 participants to classify each seizure. The diagnostic accuracy of various groups of HCPs or students for PNES versus ES was assessed, as well as the effect of patient age and sex. Measures of diagnostic accuracy included sensitivity, specificity, and area under the curve (AUC). RESULTS The descending order of diagnostic accuracy (AUC) was the following (p ≤ 0.001): (1) neurologists and epileptologists; (2) neurology residents; (3) other specialists and nurses with experience in epilepsy; and (4) undergraduate medical students. Although there was a strong trend toward statistical difference, with AUC 95% confidence intervals (CIs) that were not overlapping, between epileptologists (95% CI 93, 97) compared to neurologists (95% CI 88, 91), and neurologists compared to electroencephalography technicians (95% CI 82, 87), multiple pairwise comparisons with the conservative Tukey-Kramer honest significant difference test revealed no statistical difference (p = 0.25 and 0.1, respectively). Patient age and sex did not have an effect on diagnostic accuracy in neurology specialists. CONCLUSION Visual recognition of PNES by HCPs or students varies overall proportionately with the level of expertise in the field of neurology/epilepsy.
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Affiliation(s)
- Veronica Birca
- Division of Neurology, CHUM, Université de Montréal, Montreal, Quebec, Canada
- Division of Pediatric Neurology, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Mark R Keezer
- Division of Neurology, CHUM, Université de Montréal, Montreal, Quebec, Canada
- Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
- School of Public Health, Université de Montréal, Montreal, Quebec, Canada
| | - Laury Chamelian
- Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
- Division of Psychiatry, CHUM, Université de Montréal, Montreal, Quebec, Canada
| | - Anne Lortie
- Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
- Division of Pediatric Neurology, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Dang K Nguyen
- Division of Neurology, CHUM, Université de Montréal, Montreal, Quebec, Canada
- Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
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Lay J, Seneviratne U, Fok A, Roberts H, Phan T. Discovering themes in medical records of patients with psychogenic non-epileptic seizures. BMJ Neurol Open 2021; 2:e000087. [PMID: 33681804 PMCID: PMC7903185 DOI: 10.1136/bmjno-2020-000087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/22/2020] [Accepted: 09/27/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction Epileptic and psychogenic non-epileptic seizures (PNES) are common diagnostic problems encountered in hospital practice. This study explores the use of unsupervised machine learning in discovering themes in medical records of patients presenting with PNES. We hypothesised that themes generated by machine learning are comparable with the classification by human experts. Methods This is a retrospective analysis of the medical records in the emergency department of patients (age >18 years) with PNES who underwent inpatient video-electroencephalography monitoring from May 2009 to June 2014 and received a final diagnosis of PNES. Prior to machine learning of written text, we applied a standardised approach in natural language processing to create a document-term matrix (removal of numbers, stop-words and punctuations, transforming fonts to lower case). The words were separated into tokens and treated as if existing within a bag-of-words. A probability of each word existing within a topic (theme) was modelled on multivariate Dirichlet distribution (R Foundation, V.3.5.0). Next, we asked four experts to independently provide a clinical interpretation of the generated topics. When the majority of (≥3) experts agreed, it was regarded as highly congruent. Interactive data are available on the web at (https://gntem2.github.io/PNES/%23topic=1&lambda=0.6&term=). Results There were 39 patients (74.4% women, median age 35 years with range 20-82). A total of 121 documents were converted to text files for text mining. There were 15 generated topics with 12/15 topics rated as highly congruent. The main themes were about descriptors of seizures and medication use. Conclusions The findings from machine learning on PNES-related documentation provides evidence for the feasibility of applying machine-learning methodology to analyse large volumes of medical records. The topics generated by machine learning were congruent with interpretations by clinicians indicating this method can be used for screening of medical conditions among large volumes of medical records.
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Affiliation(s)
- Joshua Lay
- Department of Medicine, Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Udaya Seneviratne
- Department of Medicine, Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Neurology, Monash Medical Centre, Clayton, Victoria, Australia
| | - Anthony Fok
- Department of Neurology, Monash Medical Centre, Clayton, Victoria, Australia
| | - Helene Roberts
- Department of Neurology, Monash Medical Centre, Clayton, Victoria, Australia
| | - Thanh Phan
- Department of Medicine, Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Neurology, Monash Medical Centre, Clayton, Victoria, Australia
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Kerr WT, Zhang X, Hill CE, Janio EA, Chau AM, Braesch CT, Le JM, Hori JM, Patel AB, Allas CH, Karimi AH, Dubey I, Sreenivasan SS, Gallardo NL, Bauirjan J, Hwang ES, Davis EC, D'Ambrosio SR, Al Banna M, Cho AY, Dewar SR, Engel J, Feusner JD, Stern JM. Epilepsy, dissociative seizures, and mixed: Associations with time to video-EEG. Seizure 2021; 86:116-122. [PMID: 33601302 PMCID: PMC7979505 DOI: 10.1016/j.seizure.2021.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/23/2021] [Accepted: 02/02/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Video-electroencephalographic monitoring (VEM) is a core component to the diagnosis and evaluation of epilepsy and dissociative seizures (DS)-also known as functional or psychogenic seizures-but VEM evaluation often occurs later than recommended. To understand why delays occur, we compared how patient-reported clinical factors were associated with time from first seizure to VEM (TVEM) in patients with epilepsy, DS or mixed. METHODS We acquired data from 1245 consecutive patients with epilepsy, VEM-documented DS or mixed epilepsy and DS. We used multivariate log-normal regression with recursive feature elimination (RFE) to evaluate which of 76 clinical factors interacting with patients' diagnoses were associated with TVEM. RESULTS The mean and median TVEM were 14.6 years and 10 years, respectively (IQR 3-23 years). In the multivariate RFE model, the factors associated with longer TVEM in all patients included unemployment and not student status, more antiseizure medications (current and past), concussion, and ictal behavior suggestive of temporal lobe epilepsy. Average TVEM was shorter for DS than epilepsy, particularly for patients with depression, anxiety, migraines, and eye closure. Average TVEM was longer specifically for patients with DS taking more medications, more seizure types, non-metastatic cancer, and with other psychiatric comorbidities. CONCLUSIONS In all patients with seizures, trials of numerous antiseizure medications, unemployment and non-student status was associated with longer TVEM. These associations highlight a disconnect between International League Against Epilepsy practice parameters and observed referral patterns in epilepsy. In patients with dissociative seizures, some but not all factors classically associated with DS reduced TVEM.
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Affiliation(s)
- Wesley T Kerr
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States.
| | - Xingruo Zhang
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Chloe E Hill
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
| | - Emily A Janio
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Andrea M Chau
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Chelsea T Braesch
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Justine M Le
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Jessica M Hori
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Akash B Patel
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Corinne H Allas
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Amir H Karimi
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Ishita Dubey
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Siddhika S Sreenivasan
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Norma L Gallardo
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Janar Bauirjan
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Eric S Hwang
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Emily C Davis
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Shannon R D'Ambrosio
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Mona Al Banna
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Andrew Y Cho
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Sandra R Dewar
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jerome Engel
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States; Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Brain Research Institute, University of California Los Angeles, Los Angeles, CA, United States
| | - Jamie D Feusner
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - John M Stern
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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12
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Lenio S, Kerr WT, Watson M, Baker S, Bush C, Rajic A, Strom L. Validation of a predictive calculator to distinguish between patients presenting with dissociative versus epileptic seizures. Epilepsy Behav 2021; 116:107767. [PMID: 33545649 PMCID: PMC7951947 DOI: 10.1016/j.yebeh.2021.107767] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 01/30/2023]
Abstract
Dissociative seizures (also known as psychogenic nonepileptic seizures) are a common functional neurological disorder that can be difficult to distinguish from epileptic seizures. Patients with dissociative seizures provide diagnostic challenges, leading to delays in care, inappropriate care, and significant healthcare utilization and associated costs. The dissociative seizure likelihood score (DSLS) was developed by Kerr and colleagues at UCLA to distinguish between patients with epileptic seizures and dissociative seizures based on clinical and medication history as well as features of seizure semiology. We validated this calculator at the University of Colorado, which is a Level 4 National Association of Epilepsy Center. The DSLS accurately predicted the diagnosis in 81% of patients, despite local variability in the factors associated with epileptic versus dissociative seizures between the two populations. The DSLS can be a useful tool to assist with history taking and may have important utility for clinical decision making with these difficult to distinguish patient populations.
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Affiliation(s)
- Steven Lenio
- Department of Neurology, University of Colorado, Aurora, CO, USA.
| | - Wesley T Kerr
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Meagan Watson
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Sarah Baker
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Chad Bush
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Alex Rajic
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Laura Strom
- Department of Neurology, University of Colorado, Aurora, CO, USA
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13
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Xiang X, Fang J, Guo Y. Differential diagnosis between epileptic seizures and psychogenic nonepileptic seizures based on semiology. ACTA EPILEPTOLOGICA 2019. [DOI: 10.1186/s42494-019-0008-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Psychogenic nonepileptic seizures present as paroxysmal symptoms and signs mimicking epileptic seizures. The gold standard test is the synchronous recording by video, electrocardiogram and electroencephalogram. However, video electroencephalogram is not available at many centers and not entirely independent of semiology. Recent studies have focused on semiological characteristics distinguishing these two circumstances. Clinical signs and symptoms provide important clues when making differential diagnosis. The purpose of this review is to help physicians differentiating psychogenic nonepileptic seizures better from epileptic seizures based on semiology, and improve care for those patients.
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Jordan H, Feehan S, Perdue I, Murray J, Goldstein LH. Exploring psychiatrists' perspectives of working with patients with dissociative seizures in the UK healthcare system as part of the CODES trial: a qualitative study. BMJ Open 2019; 9:e026493. [PMID: 31072856 PMCID: PMC6528023 DOI: 10.1136/bmjopen-2018-026493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE There is currently limited research exploring healthcare professionals' (HCPs) experiences of working with patients with dissociative seizures (DS). Existing studies do not focus on the role of psychiatrists in treating this complex condition. The objective of this study was to gain an understanding of UK-based psychiatrists' experiences of the DS patient group. Against the backdrop of a UK-wide randomised controlled trial (RCT), the focus was broadened to encompass issues arising in everyday practice with the DS patient group. DESIGN, PARTICIPANTS AND METHODS A qualitative study using semistructured interviews was undertaken with 10 psychiatrists currently working with DS patients within the context of a large RCT investigating treatments for DS. Thematic analysis was used to identify key themes and subthemes. SETTING The psychiatrists were working in Liaison or Neuropsychiatry services in England. RESULTS The key themes identified were other HCPs' attitudes to DS and the challenges of the DS patient group. There is a clear knowledge gap regarding DS for many HCPs and other clinical services can be reluctant to take referrals for this patient group. Important challenges posed by this patient group included avoidance (of difficult emotions and help), alexithymia and interpersonal difficulties. Difficulties with alexithymia meant DS patients could struggle to identify triggers for their seizures and to express their emotions. Interpersonal difficulties raised included difficulties in attachment with both HCPs and family members. CONCLUSIONS A knowledge gap for HCPs regarding DS has been identified and needs to be addressed to improve patient care. Given the complexity of the patient group and that clinicians from multiple disciplines will come into contact with DS patients, it is essential for any educational strategy to be implemented across the whole range of specialties, and to account for those already in practice as well as future trainees. TRIAL REGISTRATION NUMBER ISRCTN05681227; NCT02325544; Pre-results.
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Affiliation(s)
- Harriet Jordan
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sarah Feehan
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Iain Perdue
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Joanna Murray
- Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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15
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Rawlings GH, Reuber M. Health care practitioners’ perceptions of psychogenic nonepileptic seizures: A systematic review of qualitative and quantitative studies. Epilepsia 2018; 59:1109-1123. [DOI: 10.1111/epi.14189] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Gregg H. Rawlings
- Academic Neurology Unit; University of Sheffield; Sheffield UK
- Academic Unit of Elderly Care and Rehabilitation; Bradford Teaching Hospitals NHS Foundation Trust; Bradford UK
| | - Markus Reuber
- Academic Neurology Unit; University of Sheffield; Sheffield UK
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16
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An Overview of Psychogenic Non-Epileptic Seizures: Etiology, Diagnosis and Management. Can J Neurol Sci 2018; 45:130-136. [DOI: 10.1017/cjn.2017.283] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AbstractThe purpose of this review is to provide an update of the research regarding the etiology, diagnosis and management of psychogenic non-epileptic seizures (PNES). A literature search using Pubmed, Ovid MEDLINE and EMBASE database was performed from 2000 up to August 2017. We have evaluated the different factors leading to PNES as well as the diagnostic approach and management of this disorder which continue to be very difficult. The coexistence of epilepsy and PNES poses special challenges and requires the coordinated efforts of the family physicians, psychiatrists, psychologists and neurologists. Although this condition has an overall poor prognosis, a multidisciplinary approach in the diagnosis and management of this disorder would likely improve the outcomes. We have proposed a diagnostic and treatment algorithm for PNES and suggested a national registry of patients suffering from this condition. The registry would contain data regarding treatment and outcomes to aid in the understanding of this entity.
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17
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Engaging psychiatrists in the diagnosis of psychogenic nonepileptic seizures. What can they contribute? Seizure 2017; 52:182-187. [DOI: 10.1016/j.seizure.2017.10.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 11/19/2022] Open
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18
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E-learning in neurology education: Principles, opportunities and challenges in combating neurophobia. J Clin Neurosci 2017; 44:80-83. [DOI: 10.1016/j.jocn.2017.06.049] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 06/19/2017] [Indexed: 11/20/2022]
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19
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Differential diagnosis of a paroxysmal neurological event: Do neurologists know how to clinically recognize it? Epilepsy Behav 2017; 67:77-83. [PMID: 28092837 DOI: 10.1016/j.yebeh.2016.12.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 12/15/2016] [Accepted: 12/17/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE To investigate ability to recognize paroxysmal neurological events (PNE) based on video-recorded events alone in a group of physicians treating prevalent neurological conditions. METHODS Total of 12 patients' videos (6 epileptic seizures (ES), 4 psychogenic nonepileptic seizures (PNES), 2 other nonepileptic seizures (oNES)) were selected. Videos were displayed once to physicians blind to clinical data and final diagnosis. Physicians determined their clinical choice: ES, PNES, oNES, and I don't know (IDK). When ES was chosen, subjects determined type of ES: focal ES, secondary generalized tonic-clonic seizure (GTCS), primary GTCS, and IDK. RESULTS In total 145 physicians (62% female, mean age 46.2±9years) (neurologists 58.6%, neuropsychiatrists 25.5%, psychiatrists 5%, and neurology residents 10.3%) were enrolled. Physician's exposure to patients with epilepsy per week was diverse: ≤1 patient (43.7%); 1-7 patients (37.2%); >7 patients (14.5%). Reported frequency of observation of PNE was as follows: frequent (21.4%), sometimes (47.6%); rarely (26.9%); never (2.1%). Majority of subjects were not EEG readers (60.7%). Median percentage (Mdn%) of correct answers (CA) was 75% (range 25-100). Predictor of better PNE recognition was higher frequency of clinical exposure to PNE (OR 1.65; CI95% 1.11-2.45; p=0.013). Mdn% of ES CA was 83.3%, (range 33.3-100), and of PNES CA was 50% (range 0-100). Physicians were more accurate in ES than PNES identification (p<0,001). Mdn% of type of ES CA was 50%, (range 0-100). CONCLUSIONS We demonstrate the need for education about clinical features of PNE across subgroups of physicians who deliver neurological service, with emphasis on PNES and ES type classification.
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Wardrope A, Reuber M. Diagnosis by Documentary: Professional Responsibilities in Informal Encounters. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:40-50. [PMID: 27749168 DOI: 10.1080/15265161.2016.1222008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Most work addressing clinical workers' professional responsibilities concerns the norms of conduct within established professional-patient relationships, but such responsibilities may extend beyond the clinical context. We explore health workers' professional responsibilities in such "informal" encounters through the example of a doctor witnessing the misdiagnosis and mistreatment of a serious long-term condition in a television documentary, arguing that neither internalist approaches to professional responsibility (such as virtue ethics or care ethics) nor externalist ones (such as the "social contract" model) provide sufficiently clear guidance in such situations. We propose that a mix of both approaches, emphasizing the noncomplacency and practical wisdom of virtue ethics, but grounding the normative authority of virtue in an external source, is able to engage with the health worker's responsibilities in such situations to the individual, the health care system, and the population at large.
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21
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Erba G, Giussani G, Juersivich A, Magaudda A, Chiesa V, Laganà A, Di Rosa G, Bianchi E, Langfitt J, Beghi E. The semiology of psychogenic nonepileptic seizures revisited: Can video alone predict the diagnosis? Preliminary data from a prospective feasibility study. Epilepsia 2016; 57:777-85. [DOI: 10.1111/epi.13351] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Giuseppe Erba
- Department of Neurology; SEC; University of Rochester; Rochester New York U.S.A
| | - Giorgia Giussani
- Laboratory of Neurological Disorders; Department of Neuroscience; IRCCS-Pharmacological Research Institute “Mario Negri”; Milan Italy
| | - Adam Juersivich
- Department of Neurology; SEC; University of Rochester; Rochester New York U.S.A
| | - Adriana Magaudda
- Department of Neuroscience; Epilepsy Center; University of Messina; Messina Italy
| | - Valentina Chiesa
- Neurology Unit 2; Epilepsy Center; San Paolo Hospital; Milan Italy
| | - Angela Laganà
- Department of Neuroscience; Epilepsy Center; University of Messina; Messina Italy
| | - Gabriella Di Rosa
- Department of Pediatric, Gynecological, Microbiological and Biomedical Science; Unit of Infantile Neuropsychiatry; University of Messina; Messina Italy
| | - Elisa Bianchi
- Laboratory of Neurological Disorders; Department of Neuroscience; IRCCS-Pharmacological Research Institute “Mario Negri”; Milan Italy
| | - John Langfitt
- Department of Neurology; SEC; University of Rochester; Rochester New York U.S.A
| | - Ettore Beghi
- Laboratory of Neurological Disorders; Department of Neuroscience; IRCCS-Pharmacological Research Institute “Mario Negri”; Milan Italy
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22
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De Paola L, Terra VC, Silvado CE, Teive HAG, Palmini A, Valente KD, Olandoski M, LaFrance WC. Improving first responders' psychogenic nonepileptic seizures diagnosis accuracy: Development and validation of a 6-item bedside diagnostic tool. Epilepsy Behav 2016; 54:40-6. [PMID: 26645799 DOI: 10.1016/j.yebeh.2015.10.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 10/24/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Epileptic seizures (ES) are often seen as a medical emergency, and their immediate and accurate recognition are pivotal in providing acute care. However, a number of clinical situations may mimic ES, potentially leading to misdiagnosis at the emergency room and to inappropriate prescription of antiepileptic drugs (AED) in the acute and chronic settings. Psychogenic nonepileptic seizures (PNES) play a major role in this scenario and often delay the correct diagnosis and increase treatment morbidity and cost. First responders often conduct the initial assessment of these patients, and their impression may be decisive in the prehospital approach to seizures. We sought to investigate and improve the accuracy of PNES diagnosis among professionals involved in the initial assistance to patients with seizures. METHODS Fifty-three registered nurses, 34 emergency physicians, 33 senior year medical students, and 12 neurology residents took a short training program consisting of an initial video-based seizure assessment test (pretest), immediately followed by a 30-minute presentation of a 6-item bedside diagnostic tool and then a video-based reassessment (posttest). Baseline status and learning curves were determined. RESULTS The distinct professional categories showed no significant differences in their ability to diagnose PNES on both pretests and posttests. All groups improved diagnostic skills after the instructional program. SIGNIFICANCE The findings helped determine the best identifiable PNES clinical signs and to provide initial validation to a novel diagnostic instrument. In addition, our results showed that educational measures might help in the identification of PNES by first responders, which may decrease the treatment gap.
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Affiliation(s)
- Luciano De Paola
- Epilepsy and EEG Service, Hospital de Clínicas, Federal University of Paraná, Brazil; EPICENTRO, Comprehensive Epilepsy Center, Hospital N S das Graças, Curitiba, Paraná, Brazil.
| | - Vera Cristina Terra
- Epilepsy and EEG Service, Hospital de Clínicas, Federal University of Paraná, Brazil; EPICENTRO, Comprehensive Epilepsy Center, Hospital N S das Graças, Curitiba, Paraná, Brazil
| | - Carlos Eduardo Silvado
- Epilepsy and EEG Service, Hospital de Clínicas, Federal University of Paraná, Brazil; EPICENTRO, Comprehensive Epilepsy Center, Hospital N S das Graças, Curitiba, Paraná, Brazil
| | | | - Andre Palmini
- Service of Neurology, Porto Alegre Epilepsy Surgery Program, The Brain Institute (InsCer), Pontificia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Kette Dualibi Valente
- Psychiatric Department, Clinic's Hospital, University of São Paulo, Brazil; Clinical Neurophysiology Laboratory, Clinic's Hospital, University of São Paulo, Brazil
| | - Márcia Olandoski
- Medical School, Pontificia Universidade Católica do Paraná, Brazil
| | - W Curt LaFrance
- Psychiatry Department, Brown Medical School, Rhode Island Hospital, Providence, RI, USA; Neurology Department, Brown Medical School, Rhode Island Hospital, Providence, RI, USA
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23
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Seneviratne U, Ma H, Phan TG. How do doctors in training react to seizures? Epilepsy Behav 2016; 54:104-9. [PMID: 26700064 DOI: 10.1016/j.yebeh.2015.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 10/20/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIMS There are scant data on how doctors approach seizures in the acute setting. We sought to study (a) exposure to seizure disorders as well as relevant training and (b) reactions to seizures in the acute setting, among medical residents undergoing physician training. METHODS The exposure to and training on seizure disorders were assessed using a structured questionnaire first. Then, they were tested with 20 videos consisting of 10 epileptic seizures (ESs) and 10 psychogenic nonepileptic seizures (PNESs). After each video, we asked three questions to test (a) the diagnosis and the practice of administration of benzodiazepines to terminate the seizure, (b) the estimation of seizure duration, and (c) the practice of intubation. The accuracy of diagnosis was measured by the area under the summary receiver operating characteristics curve (AUC). The difference between true seizure duration and estimated duration was evaluated using paired-sample t-test. RESULTS A total of 48 trainees participated in the study. The majority witnessed seizures in movies (37, 77.1%) and television (35, 72.9%). Only 12 (25%) received bedside teaching on seizure disorders. Their diagnostic accuracy of seizures was very poor (AUC=0.54). Participants significantly underestimated the duration of seizures. Thirty-five doctors made an illogical decision to intubate but not to terminate the seizure with intravenous benzodiazepine. CONCLUSIONS The diagnostic accuracy of seizures is poor among trainees, and their estimates of seizure duration are unreliable. Our study highlights potential pitfalls in the acute management of seizures and the need for more training on seizure disorders.
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Affiliation(s)
- Udaya Seneviratne
- Department of Neurosciences, Monash Health, Monash Medical Centre, Melbourne, Australia; Department of Medicine, Monash University, Melbourne, Australia.
| | - Henry Ma
- Department of Neurosciences, Monash Health, Monash Medical Centre, Melbourne, Australia; Department of Medicine, Monash University, Melbourne, Australia.
| | - Thanh G Phan
- Department of Neurosciences, Monash Health, Monash Medical Centre, Melbourne, Australia; Department of Medicine, Monash University, Melbourne, Australia.
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Wiseman H, Reuber M. New insights into psychogenic nonepileptic seizures 2011-2014. Seizure 2015; 29:69-80. [PMID: 26076846 DOI: 10.1016/j.seizure.2015.03.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/24/2015] [Accepted: 03/11/2015] [Indexed: 10/23/2022] Open
Abstract
PURPOSE There has been a rapid increase in the rate of publications about psychogenic nonepileptic seizures (PNES). This review summarises insights from the 50 most important original articles about PNES published since 2011 and describes the advances made in the understanding of PNES over the last 3 years. METHOD We carried out a systematic literature search of all English language publications about PNES published between October 2011 and October 2014 on Scopus, Ovid Medline and Web of Knowledge, and inspected all abstracts. Having excluded all review articles, case reports, conference abstracts, articles exploring PNES in children, and articles not actually focussing on PNES, we considered 150 papers for inclusion in this review. We assessed the quality of the identified studies and used expert judgement to identify the 50 most important publications from the review period and composed a narrative review based on these original papers. RESULTS Almost one half of the studies initially identified only provided Class 4 evidence. Recent work has provided more support for a biopsychosocial account of PNES. It has illustrated the heterogeneity of PNES, identifying varying and distinct psychological profiles of individuals with this disorder. These findings suggest that intervention needs to be flexible or adaptive if it is appropriately to target the different mechanisms which may give rise to PNES. Several educational and psychotherapeutic interventions for PNES have been described, but sufficiently powered randomised controlled trials are yet to be undertaken. Recent research using social, economic and quality of life indicators has provided further evidence of the societal and individual burden of PNES. CONCLUSION The research into PNES published over the last 3 years has deepened our understanding of the condition as a biopsychosocial disorder which is neither a "physical" nor a "psychological" condition. A number of small studies have demonstrated the potential of educational and psychotherapeutic treatments, but rigorous and sufficiently large trials still need to be conducted to determine the effectiveness of these interventions.
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Affiliation(s)
- Hannah Wiseman
- Academic Neurology Unit, University of Sheffield, United Kingdom.
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, United Kingdom
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25
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Analyzing reliability of seizure diagnosis based on semiology. Epilepsy Behav 2014; 41:197-202. [PMID: 25461215 DOI: 10.1016/j.yebeh.2014.09.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 09/07/2014] [Accepted: 09/20/2014] [Indexed: 11/21/2022]
Abstract
This study aimed to determine the accuracy of seizure diagnosis by semiological analysis and to assess the factors that affect diagnostic reliability. A total of 150 video clips of seizures from 50 patients (each with three seizures of the same type) were observed by eight epileptologists, 12 neurologists, and 20 physicians (internists). The videos included 37 series of epileptic seizures, eight series of physiologic nonepileptic events (PNEEs), and five series of psychogenic nonepileptic seizures (PNESs). After observing each video, the doctors chose the diagnosis of epileptic seizures or nonepileptic events for the patient; if the latter was chosen, they further chose the diagnosis of PNESs or PNEEs. The overall diagnostic accuracy rate for epileptic seizures and nonepileptic events increased from 0.614 to 0.660 after observations of all three seizures (p < 0.001). The diagnostic sensitivity and specificity of epileptic seizures were 0.770 and 0.808, respectively, for the epileptologists. These values were significantly higher than those for the neurologists (0.660 and 0.699) and physicians (0.588 and 0.658). A wide range of diagnostic accuracy was found across the various seizures types. An accuracy rate of 0.895 for generalized tonic-clonic seizures was the highest, followed by 0.800 for dialeptic seizures and then 0.760 for automotor seizures. The accuracy rates for myoclonic seizures (0.530), hypermotor seizures (0.481), gelastic/dacrystic seizures (0.438), and PNESs (0.430) were poor. The reliability of semiological diagnosis of seizures is greatly affected by the seizure type as well as the doctor's experience. Although the overall reliability is limited, it can be improved by observing more seizures.
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