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Beaulieu-Jones BK, Villamar MF, Scordis P, Bartmann AP, Ali W, Wissel BD, Alsentzer E, de Jong J, Patra A, Kohane I. Predicting seizure recurrence after an initial seizure-like episode from routine clinical notes using large language models: a retrospective cohort study. Lancet Digit Health 2023; 5:e882-e894. [PMID: 38000873 PMCID: PMC10695164 DOI: 10.1016/s2589-7500(23)00179-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/08/2023] [Accepted: 08/31/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND The evaluation and management of first-time seizure-like events in children can be difficult because these episodes are not always directly observed and might be epileptic seizures or other conditions (seizure mimics). We aimed to evaluate whether machine learning models using real-world data could predict seizure recurrence after an initial seizure-like event. METHODS This retrospective cohort study compared models trained and evaluated on two separate datasets between Jan 1, 2010, and Jan 1, 2020: electronic medical records (EMRs) at Boston Children's Hospital and de-identified, patient-level, administrative claims data from the IBM MarketScan research database. The study population comprised patients with an initial diagnosis of either epilepsy or convulsions before the age of 21 years, based on International Classification of Diseases, Clinical Modification (ICD-CM) codes. We compared machine learning-based predictive modelling using structured data (logistic regression and XGBoost) with emerging techniques in natural language processing by use of large language models. FINDINGS The primary cohort comprised 14 021 patients at Boston Children's Hospital matching inclusion criteria with an initial seizure-like event and the comparison cohort comprised 15 062 patients within the IBM MarketScan research database. Seizure recurrence based on a composite expert-derived definition occurred in 57% of patients at Boston Children's Hospital and 63% of patients within IBM MarketScan. Large language models with additional domain-specific and location-specific pre-training on patients excluded from the study (F1-score 0·826 [95% CI 0·817-0·835], AUC 0·897 [95% CI 0·875-0·913]) performed best. All large language models, including the base model without additional pre-training (F1-score 0·739 [95% CI 0·738-0·741], AUROC 0·846 [95% CI 0·826-0·861]) outperformed models trained with structured data. With structured data only, XGBoost outperformed logistic regression and XGBoost models trained with the Boston Children's Hospital EMR (logistic regression: F1-score 0·650 [95% CI 0·643-0·657], AUC 0·694 [95% CI 0·685-0·705], XGBoost: F1-score 0·679 [0·676-0·683], AUC 0·725 [0·717-0·734]) performed similarly to models trained on the IBM MarketScan database (logistic regression: F1-score 0·596 [0·590-0·601], AUC 0·670 [0·664-0·675], XGBoost: F1-score 0·678 [0·668-0·687], AUC 0·710 [0·703-0·714]). INTERPRETATION Physician's clinical notes about an initial seizure-like event include substantial signals for prediction of seizure recurrence, and additional domain-specific and location-specific pre-training can significantly improve the performance of clinical large language models, even for specialised cohorts. FUNDING UCB, National Institute of Neurological Disorders and Stroke (US National Institutes of Health).
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Affiliation(s)
- Brett K Beaulieu-Jones
- Department of Medicine, University of Chicago, Chicago, IL, USA; Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA.
| | - Mauricio F Villamar
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | | | - Benjamin D Wissel
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Emily Alsentzer
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | | | | | - Isaac Kohane
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
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Neligan A, Adan G, Nevitt SJ, Pullen A, Sander JW, Bonnett L, Marson AG. Prognosis of adults and children following a first unprovoked seizure. Cochrane Database Syst Rev 2023; 1:CD013847. [PMID: 36688481 PMCID: PMC9869434 DOI: 10.1002/14651858.cd013847.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Epilepsy is clinically defined as two or more unprovoked epileptic seizures more than 24 hours apart. Given that, a diagnosis of epilepsy can be associated with significant morbidity and mortality, it is imperative that clinicians (and people with seizures and their relatives) have access to accurate and reliable prognostic estimates, to guide clinical practice on the risks of developing further unprovoked seizures (and by definition, a diagnosis of epilepsy) following single unprovoked epileptic seizure. OBJECTIVES 1. To provide an accurate estimate of the proportion of individuals going on to have further unprovoked seizures at subsequent time points following a single unprovoked epileptic seizure (or cluster of epileptic seizures within a 24-hour period, or a first episode of status epilepticus), of any seizure type (overall prognosis). 2. To evaluate the mortality rate following a first unprovoked epileptic seizure. SEARCH METHODS We searched the following databases on 19 September 2019 and again on 30 March 2021, with no language restrictions. The Cochrane Register of Studies (CRS Web), MEDLINE Ovid (1946 to March 29, 2021), SCOPUS (1823 onwards), ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). CRS Web includes randomized or quasi-randomized, controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the Specialized Registers of Cochrane Review Groups including Epilepsy. In MEDLINE (Ovid) the coverage end date always lags a few days behind the search date. SELECTION CRITERIA We included studies, both retrospective and prospective, of all age groups (except those in the neonatal period (< 1 month of age)), of people with a single unprovoked seizure, followed up for a minimum of six months, with no upper limit of follow-up, with the study end point being seizure recurrence, death, or loss to follow-up. To be included, studies must have included at least 30 participants. We excluded studies that involved people with seizures that occur as a result of an acute precipitant or provoking factor, or in close temporal proximity to an acute neurological insult, since these are not considered epileptic in aetiology (acute symptomatic seizures). We also excluded people with situational seizures, such as febrile convulsions. DATA COLLECTION AND ANALYSIS Two review authors conducted the initial screening of titles and abstracts identified through the electronic searches, and removed non-relevant articles. We obtained the full-text articles of all remaining potentially relevant studies, or those whose relevance could not be determined from the abstract alone and two authors independently assessed for eligibility. All disagreements were resolved through discussion with no need to defer to a third review author. We extracted data from included studies using a data extraction form based on the checklist for critical appraisal and data extraction for systematicreviews of prediction modelling studies (CHARMS). Two review authors then appraised the included studies, using a standardised approach based on the quality in prognostic studies (QUIPS) tool, which was adapted for overall prognosis (seizure recurrence). We conducted a meta-analysis using Review Manager 2014, with a random-effects generic inverse variance meta-analysis model, which accounted for any between-study heterogeneity in the prognostic effect. We then summarised the meta-analysis by the pooled estimate (the average prognostic factor effect), its 95% confidence interval (CI), the estimates of I² and Tau² (heterogeneity), and a 95% prediction interval for the prognostic effect in a single population at three various time points, 6 months, 12 months and 24 months. Subgroup analysis was performed according to the ages of the cohorts included; studies involving all ages, studies that recruited adult only and those that were purely paediatric. MAIN RESULTS Fifty-eight studies (involving 54 cohorts), with a total of 12,160 participants (median 147, range 31 to 1443), met the inclusion criteria for the review. Of the 58 studies, 26 studies were paediatric studies, 16 were adult and the remaining 16 studies were a combination of paediatric and adult populations. Most included studies had a cohort study design with two case-control studies and one nested case-control study. Thirty-two studies (29 cohorts) reported a prospective longitudinal design whilst 15 studies had a retrospective design whilst the remaining studies were randomised controlled trials. Nine of the studies included presented mortality data following a first unprovoked seizure. For a mortality study to be included, a proportional mortality ratio (PMR) or a standardised mortality ratio (SMR) had to be given at a specific time point following a first unprovoked seizure. To be included in the meta-analysis a study had to present clear seizure recurrence data at 6 months, 12 months or 24 months. Forty-six studies were included in the meta-analysis, of which 23 were paediatric, 13 were adult, and 10 were a combination of paediatric and adult populations. A meta-analysis was performed at three time points; six months, one year and two years for all ages combined, paediatric and adult studies, respectively. We found an estimated overall seizure recurrence of all included studies at six months of 27% (95% CI 24% to 31%), 36% (95% CI 33% to 40%) at one year and 43% (95% CI 37% to 44%) at two years, with slightly lower estimates for adult subgroup analysis and slightly higher estimates for paediatric subgroup analysis. It was not possible to provide a summary estimate of the risk of seizure recurrence beyond these time points as most of the included studies were of short follow-up and too few studies presented recurrence rates at a single time point beyond two years. The evidence presented was found to be of moderate certainty. AUTHORS' CONCLUSIONS Despite the limitations of the data (moderate-certainty of evidence), mainly relating to clinical and methodological heterogeneity we have provided summary estimates for the likely risk of seizure recurrence at six months, one year and two years for both children and adults. This provides information that is likely to be useful for the clinician counselling patients (or their parents) on the probable risk of further seizures in the short-term whilst acknowledging the paucity of long-term recurrence data, particularly beyond 10 years.
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Affiliation(s)
- Aidan Neligan
- Homerton University Hospital, NHS Foundation Trust, London, UK
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Guleed Adan
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Sarah J Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | | | - Josemir W Sander
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Laura Bonnett
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- Liverpool Health Partners, Liverpool, UK
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Marson T. Evidence-based policy for driving: easier said than done. Pract Neurol 2022; 22:266-267. [PMID: 35654575 DOI: 10.1136/practneurol-2022-003458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Tony Marson
- Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK .,Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
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Pang E, Lawn N, Lee J, Dunne J. Identification and Characterization of Pure Sleep Epilepsy in a Cohort of Patients With a First Seizure. Neurology 2022; 98:e1857-e1864. [PMID: 35288461 DOI: 10.1212/wnl.0000000000200149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 01/18/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To study the development of pure sleep epilepsy (PSE) after a first-ever seizure from sleep in adults. METHODS Prospective observational study of patients seen at a tertiary hospital-based first seizure clinic between 2000 and 2011. Adults with a first-ever unprovoked seizure from sleep were consecutively recruited. All patients were followed up at least once after the initial seizure and those not requiring regular clinical review were contacted every one to two years. The timing and pattern of subsequent seizures as well as potential predictors of future awake seizures were analyzed. RESULTS 239 adults with a first-ever unprovoked seizure from sleep were identified, 61% male; mean age 43 years (range 14-88 years) and median follow-up of 8.8 years (range 2 months -18 years). Of the 174 patients who had recurrent seizures, 130 patients (75%) had their second seizure from sleep, and of these, 76 of 94 (81%) also had their third seizure from sleep. 89 patients (37%) developed awake seizures during follow up. In half of these patients, the awake seizure occurred within two years of the initial seizure. The risk of an awake seizure within 1 year of a first-ever seizure from sleep was 13.9% (95%CI 9.4-18.3), falling to 2.0-5.3% per year after 3 years. The risks of an awake seizure within 1 year of a second or third consecutive sleep seizure were 9.9% (95%CI 4.6-15.3) and 8.7% (95%CI 2.0-15.4) respectively, and similarly decreased with time. CONCLUSION Most initial seizure recurrences after a first-ever sleep seizure occur during sleep. Whilst over one third eventually had awake seizures, the annual risk of an awake seizure was ≤14% and decreased with time, albeit with a small ongoing risk of between 2 and 5% per year. These findings may be utilized in counselling patients with seizures from sleep and inform driving recommendations.
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Affiliation(s)
- Elaine Pang
- Western Australian Adult Epilepsy Service, Perth, Western Australia
| | - Nicholas Lawn
- Western Australian Adult Epilepsy Service, Perth, Western Australia
| | - Judy Lee
- Western Australian Adult Epilepsy Service, Perth, Western Australia
| | - John Dunne
- School of Medicine, Royal Perth Hospital Unit, University of Western Australia
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Bonnett LJ, Kim L, Johnson A, Sander JW, Lawn N, Beghi E, Leone M, Marson AG. Risk of seizure recurrence in people with single seizures and early epilepsy - Model development and external validation. Seizure 2021; 94:26-32. [PMID: 34852983 PMCID: PMC8776562 DOI: 10.1016/j.seizure.2021.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/19/2021] [Accepted: 11/21/2021] [Indexed: 11/29/2022] Open
Abstract
Model predicts risk of seizure recurrence after single fit or epilepsy diagnosis. Model performs well in independent data. Future work required to ensure the model is adopted in clinical practice. Model can improve the lives of people with single seizures and early epilepsy.
Purpose Following a single seizure, or recent epilepsy diagnosis, it is difficult to balance risk of medication side effects with the potential to prevent seizure recurrence. A prediction model was developed and validated enabling risk stratification which in turn informs treatment decisions and individualises counselling. Methods Data from a randomised controlled trial was used to develop a prediction model for risk of seizure recurrence following a first seizure or diagnosis of epilepsy. Time-to-event data was modelled via Cox's proportional hazards regression. Model validity was assessed via discrimination and calibration using the original dataset and also using three external datasets – National General Practice Survey of Epilepsy (NGPSE), Western Australian first seizure database (WA) and FIRST (Italian dataset of people with first tonic-clonic seizures). Results People with neurological deficit, focal seizures, abnormal EEG, not indicated for CT/MRI scan, or not immediately treated have a significantly higher risk of seizure recurrence. Discrimination was fair and consistent across the datasets (c-statistics: 0.555 (NGPSE); 0.558 (WA); 0.597 (FIRST)). Calibration plots showed good agreement between observed and predicted probabilities in NGPSE at one and three years. Plots for WA and FIRST showed poorer agreement with the model underpredicting risk in WA, and over-predicting in FIRST. This was resolved following model recalibration. Conclusion The model performs well in independent data especially when recalibrated. It should now be used in clinical practice as it can improve the lives of people with single seizures and early epilepsy by enabling targeted treatment choices and more informed patient counselling.
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Affiliation(s)
- Laura J Bonnett
- Department of Health Data Science, University of Liverpool, Block B, Waterhouse Building, Brownlow Hill, Liverpool L69 3GL United Kingdom.
| | - Lois Kim
- Cardiovascular Epidemiology Unit, Strangeways Research Laboratory, University of Cambridge, Wort's Causeway, Cambridge CB1 8RN, United Kingdom.
| | - Anthony Johnson
- Medical Research Council Clinical Trials Unit, UCL Institute of Clinical Trials and Methodology, London, WC1V 6LJ, United Kingdom.
| | - Josemir W Sander
- NIHR University College London Hospitals Biomedical Research Centre, London W1T 7DN, United Kingdom; UCL Queen Square Institute of Neurology, London WC1N 3BG, United Kingdom; Chalfont Centre for Epilepsy, Chalfont St Peter, SL9 0RJ, United Kingdom; Stichting Epilepsie Instelligen Nederland (SEIN), Heemstede 2103 SW, the Netherlands.
| | - Nicholas Lawn
- Western Australian Adult Epilepsy Service, Perth, Australia.
| | - Ettore Beghi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy.
| | - Maurizio Leone
- Fondazione IRCCS Casa Sollievo della Sofferenza, Unit of Neurology, San Giovanni Rotondo (FG), Italy.
| | - Anthony G Marson
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom.
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Specht U, Bien CG. Driving eligibility: Implications of studies on seizure recurrence risk. Acta Neurol Scand 2020; 142:541-544. [PMID: 32740908 DOI: 10.1111/ane.13327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/06/2020] [Accepted: 07/24/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Driving is one of the most important issues for patients with seizures. The 2009 European directive provides a framework for evaluating standard situations in assessing the ability to drive. Such a framework may not be sufficient for individual scenarios. AIMS OF THE STUDY To analyse current data on seizure recurrence risks (RcRs) focusing on their potential implications for car driving issues (group 1). METHODS We evaluated current studies and meta-analyses on RcR. RESULTS A meta-analysis of seizure-free patients who withdrew their medication (Lamberink et al Lancet Neurology 2017;16:523) created a nomogram and a web-based tool that allow estimating RcR in individual patients and thus to identify those in whom medication withdrawal is possible without the common driving ban during withdrawal. The 2-year prediction model of that meta-analysis has been recently externally tested and confirmed. A meta-analysis of patients with a first unprovoked seizure (Bonnett et al PloS ONE 2014;9:e99063) determined to which extent RcRs depend on established risk factors. The seizure-free period required to restart driving could be tailored according to the individual RcR. CONCLUSION These current studies allow estimating individual RcR more precisely and thus modifying periods of driving bans beyond the existing guidelines.
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Affiliation(s)
- Ulrich Specht
- Epilepsy Centre BethelKrankenhaus Mara Bielefeld Germany
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Quantitative analysis of phenotypic elements augments traditional electroclinical classification of common familial epilepsies. Epilepsia 2019; 60:2194-2203. [PMID: 31625138 PMCID: PMC7145322 DOI: 10.1111/epi.16354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 08/16/2019] [Accepted: 09/04/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Classification of epilepsy into types and subtypes is important for both clinical care and research into underlying disease mechanisms. A quantitative, data-driven approach may augment traditional electroclinical classification and shed new light on existing classification frameworks. METHODS We used latent class analysis, a statistical method that assigns subjects into groups called latent classes based on phenotypic elements, to classify individuals with common familial epilepsies from the Epi4K Multiplex Families study. Phenotypic elements included seizure types, seizure symptoms, and other elements of the medical history. We compared class assignments to traditional electroclinical classifications and assessed familial aggregation of latent classes. RESULTS A total of 1120 subjects with epilepsy were assigned to five latent classes. Classes 1 and 2 contained subjects with generalized epilepsy, largely reflecting the distinction between absence epilepsies and younger onset (class 1) versus myoclonic epilepsies and older onset (class 2). Classes 3 and 4 contained subjects with focal epilepsies, and in contrast to classes 1 and 2, these did not adhere as closely to clinically defined focal epilepsy subtypes. Class 5 contained nearly all subjects with febrile seizures plus or unknown epilepsy type, as well as a few subjects with generalized epilepsy and a few with focal epilepsy. Family concordance of latent classes was similar to or greater than concordance of clinically defined epilepsy types. SIGNIFICANCE Quantitative classification of epilepsy has the potential to augment traditional electroclinical classification by (1) combining some syndromes into a single class, (2) splitting some syndromes into different classes, (3) helping to classify subjects who could not be classified clinically, and (4) defining the boundaries of clinically defined classifications. This approach can guide future research, including molecular genetic studies, by identifying homogeneous sets of individuals that may share underlying disease mechanisms.
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Joshi CN, Vossler DG, Spanaki M, Draszowki JF, Towne AR. "Chance Takers Are Accident Makers": Are Patients With Epilepsy Really Taking a Chance When They Drive? Epilepsy Curr 2019; 19:221-226. [PMID: 31328536 PMCID: PMC6891831 DOI: 10.1177/1535759719858647] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
This review compiles scientific data about the real dangers faced by people with
epilepsy (PWE) who drive. Those include risks of motor vehicle accidents (MVA)
in PWE as compared with controls (individuals without epilepsy) and as compared
with persons with other medical conditions that impact fitness to drive. Data
regarding Accident rates as related to seizure free intervals (SFI), single vs.
multiple seizure events, and/or antiseizure drug (ASD) taper and reintroduction
are discussed. Variation in state, national, and international laws and guidance
for non-commercial and commercial drivers is highlighted, along with some
related reasons for driving restrictions. The review concludes by emphasizing
the importance of physicians educating patients about local driving laws and
about risks of ASD non-adherence. The need for a broader, multi-stakeholder
re-examination of driving regulations for PWE is noted.
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Affiliation(s)
- Charuta N Joshi
- 1 Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus, Denver, CO, USA
| | - David G Vossler
- 2 UW Medicine
- Valley Medical Center and University of Washington, Seattle, WA, USA
| | - Marianne Spanaki
- 3 Department of Neurology, Wayne State University, Detroit, MI, USA
| | | | - Alan R Towne
- 5 Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
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Hughes DM, Bonnett LJ, Marson AG, García-Fiñana M. Identifying patients who will not reachieve remission after breakthrough seizures. Epilepsia 2019; 60:774-782. [PMID: 30900756 PMCID: PMC6487810 DOI: 10.1111/epi.14697] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 03/01/2019] [Accepted: 03/01/2019] [Indexed: 11/29/2022]
Abstract
Objective We aim to identify people with epilepsy who are unlikely to reachieve a 12‐month remission within 2 years after experiencing a breakthrough seizure following an initial 12‐month remission. Methods We apply a novel longitudinal discriminant approach to data from the Standard and New Antiepileptic Drugs study to dynamically predict the risk of a patient not achieving a second remission after a breakthrough seizure by combining both baseline covariates (collected at the time of breakthrough seizure) and follow‐up data. Results The model classifies 83% of patients. Of these, 73% of patients (95% confidence interval [CI] = 58%‐88%) who did not achieve a second remission were correctly identified (sensitivity), and 84% of patients (95% CI = 69%‐96%) who achieved a second remission were correctly identified (specificity). The area under the curve from our model was 87% (95% CI = 80%‐94%). Patients who did not achieve a second remission were correctly identified on average after 10 months of observation postbreakthrough. Occurrence of seizures after breakthrough and the number of seizures experienced were the most informative longitudinal variables. These longitudinal profiles were influenced by the following baseline covariates: age at breakthrough seizure, presence of neurological insult, and number of antiepileptic drugs required to achieve first remission. Significance Using longitudinal data gathered during patient follow‐up allows more accurate predictions than using baseline covariates in a standard Cox model. The model developed in this paper is a useful first step in developing a tool for identifying patients who develop drug resistance after an initial remission.
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Affiliation(s)
- David M Hughes
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Laura J Bonnett
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Anthony G Marson
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,The Walton Centre NHS Foundation Trust, members of Liverpool Health Partners, Liverpool, UK
| | - Marta García-Fiñana
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Hughes DM, Bonnett LJ, Czanner G, Komárek A, Marson AG, García-Fiñana M. Identification of patients who will not achieve seizure remission within 5 years on AEDs. Neurology 2018; 91:e2035-e2044. [PMID: 30389894 PMCID: PMC6282237 DOI: 10.1212/wnl.0000000000006564] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 08/15/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To identify people with epilepsy who will not achieve a 12-month seizure remission within 5 years of starting treatment. METHODS The Standard and New Antiepileptic Drug (SANAD) study is the largest prospective study in patients with epilepsy to date. We applied a recently developed multivariable approach to the SANAD dataset that takes into account not only baseline covariates describing a patient's history before diagnosis but also follow-up data as predictor variables. RESULTS Changes in number of seizures and treatment history were the most informative time-dependent predictors and were associated with history of neurologic insult, epilepsy type, age at start of treatment, sex, and having a first-degree relative with epilepsy. Our model classified 95% of patients. Of those classified, 95% of patients observed not to achieve remission at 5 years were correctly classified (95% confidence interval [CI] 89.5%-100%), with 51% identified by 3 years and 90% within 4 years of follow-up. Ninety-seven percent (95% CI 93.3%-98.8%) of patients observed to achieve a remission within 5 years were correctly classified. Of those predicted not to achieve remission, 76% (95% CI 58.5%-88.2%) truly did not achieve remission (positive predictive value). The predictive model achieved similar accuracy levels via external validation in 2 independent United Kingdom-based datasets. CONCLUSION Our approach generates up-to-date predictions of the patient's risk of not achieving seizure remission whenever new clinical information becomes available that could influence patient counseling and management decisions.
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Affiliation(s)
- David M Hughes
- From the Departments of Biostatistics (D.M.H., L.J.B., G.C., M.G.-F.) and Molecular and Clinical Pharmacology (A.G.M.), Institute of Translational Medicine, and Department of Eye and Vision Science (G.C.), Institute of Ageing & Chronic Disease, University of Liverpool, UK; and Department of Probability and Mathematical Statistics (A.K.), Faculty of Mathematics and Physics, Charles University, Prague, Czech Republic
| | - Laura J Bonnett
- From the Departments of Biostatistics (D.M.H., L.J.B., G.C., M.G.-F.) and Molecular and Clinical Pharmacology (A.G.M.), Institute of Translational Medicine, and Department of Eye and Vision Science (G.C.), Institute of Ageing & Chronic Disease, University of Liverpool, UK; and Department of Probability and Mathematical Statistics (A.K.), Faculty of Mathematics and Physics, Charles University, Prague, Czech Republic
| | - Gabriela Czanner
- From the Departments of Biostatistics (D.M.H., L.J.B., G.C., M.G.-F.) and Molecular and Clinical Pharmacology (A.G.M.), Institute of Translational Medicine, and Department of Eye and Vision Science (G.C.), Institute of Ageing & Chronic Disease, University of Liverpool, UK; and Department of Probability and Mathematical Statistics (A.K.), Faculty of Mathematics and Physics, Charles University, Prague, Czech Republic
| | - Arnošt Komárek
- From the Departments of Biostatistics (D.M.H., L.J.B., G.C., M.G.-F.) and Molecular and Clinical Pharmacology (A.G.M.), Institute of Translational Medicine, and Department of Eye and Vision Science (G.C.), Institute of Ageing & Chronic Disease, University of Liverpool, UK; and Department of Probability and Mathematical Statistics (A.K.), Faculty of Mathematics and Physics, Charles University, Prague, Czech Republic
| | - Anthony G Marson
- From the Departments of Biostatistics (D.M.H., L.J.B., G.C., M.G.-F.) and Molecular and Clinical Pharmacology (A.G.M.), Institute of Translational Medicine, and Department of Eye and Vision Science (G.C.), Institute of Ageing & Chronic Disease, University of Liverpool, UK; and Department of Probability and Mathematical Statistics (A.K.), Faculty of Mathematics and Physics, Charles University, Prague, Czech Republic
| | - Marta García-Fiñana
- From the Departments of Biostatistics (D.M.H., L.J.B., G.C., M.G.-F.) and Molecular and Clinical Pharmacology (A.G.M.), Institute of Translational Medicine, and Department of Eye and Vision Science (G.C.), Institute of Ageing & Chronic Disease, University of Liverpool, UK; and Department of Probability and Mathematical Statistics (A.K.), Faculty of Mathematics and Physics, Charles University, Prague, Czech Republic.
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Petersen JF, Stuiver MM, Timmermans AJ, Chen A, Zhang H, O'Neill JP, Deady S, Vander Poorten V, Meulemans J, Wennerberg J, Skroder C, Day AT, Koch W, van den Brekel MWM. Development and external validation of a risk-prediction model to predict 5-year overall survival in advanced larynx cancer. Laryngoscope 2017; 128:1140-1145. [DOI: 10.1002/lary.26990] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/27/2017] [Accepted: 10/09/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Japke F. Petersen
- Department of Head and Neck Surgery and Oncology; the Netherlands Cancer Institute; Amsterdam the Netherlands
| | - Martijn M. Stuiver
- Department of Head and Neck Surgery and Oncology; the Netherlands Cancer Institute; Amsterdam the Netherlands
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics; Amsterdam Medical Center; Amsterdam the Netherlands
| | - Adriana J. Timmermans
- Department of Head and Neck Surgery and Oncology; the Netherlands Cancer Institute; Amsterdam the Netherlands
| | - Amy Chen
- Department of Otolaryngology-Head and Neck Surgery; Emory University; Atlanta Georgia U.S.A
| | - Hongzhen Zhang
- Department of Otolaryngology-Head and Neck Surgery; Emory University; Atlanta Georgia U.S.A
| | - James P. O'Neill
- Department of Head and Neck Surgery and Oncology; St. James Hospital; Dublin Ireland
| | | | - Vincent Vander Poorten
- Department of Oncology, Head and Neck Oncology Section; University Hospitals Leuven; Leuven Belgium
| | - Jeroen Meulemans
- Department of Oncology, Head and Neck Oncology Section; University Hospitals Leuven; Leuven Belgium
| | - Johan Wennerberg
- Department of ENT/Head and Neck Surgery; Lund University Hospital; Lund Sweden
| | - Carl Skroder
- Department of ENT/Head and Neck Surgery; Lund University Hospital; Lund Sweden
| | - Andrew T. Day
- Department of Head and Neck Surgery and Oncology; Johns Hopkins Medical Center; Baltimore Maryland U.S.A
| | - Wayne Koch
- Department of Head and Neck Surgery and Oncology; Johns Hopkins Medical Center; Baltimore Maryland U.S.A
| | - Michiel W. M. van den Brekel
- Department of Head and Neck Surgery and Oncology; the Netherlands Cancer Institute; Amsterdam the Netherlands
- Institute of Phonetic Sciences; University of Amsterdam; Amsterdam the Netherlands
- Department of Oral and Maxillofacial Surgery; Academic Medical Center; Amsterdam the Netherlands
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12
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Dickson JM, Dudhill H, Shewan J, Mason S, Grünewald RA, Reuber M. Cross-sectional study of the hospital management of adult patients with a suspected seizure (EPIC2). BMJ Open 2017; 7:e015696. [PMID: 28706099 PMCID: PMC5541576 DOI: 10.1136/bmjopen-2016-015696] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine the clinical characteristics, management and outcomes of patients taken to hospital by emergency ambulance after a suspected seizure. DESIGN Quantitative cross-sectional retrospective study of a consecutive series of patients. SETTING An acute hospital trust in a large city in England. PARTICIPANTS In 2012-2013, the regions' ambulance service managed 605 481 emergency incidents, 74 141/605 481 originated from Sheffield (a large city in the region), 2121/74 141 (2.9%) were suspected seizures and 178/2121 occurred in May 2012. We undertook detailed analysis of the medical records of the 91/178 patients who were transported to the city's acute hospital. After undertaking a retrospective review of the medical records, the best available aetiological explanation for the seizures was determined. RESULTS The best available aetiological explanation for 74.7% (68/91) of the incidents was an epileptic seizure, 11.0% (10/91) were psychogenic non-epileptic seizures and 9.9% (9/91) were cardiogenic events. The epileptic seizures fall into the following four categories: first epileptic seizure (13.2%, 12/91), epileptic seizure with a historical diagnosis of epilepsy (30.8%, 28/91), recurrent epileptic seizures without a historical diagnosis of epilepsy (20.9%, 19/91) and acute symptomatic seizures (9.9%, 9/91). Of those with seizures (excluding cardiogenic events), 2.4% (2/82) of patients were seizing on arrival in the Emergency Department (ED), 19.5% (16/82) were postictal and 69.5% (57/82) were alert. 63.4% (52/82) were discharged at the end of their ED attendance and 36.5% (19/52) of these had no referral or follow-up. CONCLUSIONS Most suspected seizures are epileptic seizures but this is a diagnostically heterogeneous group. Only a small minority of patients require emergency medical care but most are transported to hospital. Few patients receive expert review and many are discharged home without referral to a specialist leaving them at risk of further seizures and the associated morbidity, mortality and health services costs of poorly controlled epilepsy.
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Affiliation(s)
- Jon Mark Dickson
- The Academic Unit of Primary Medical Care, The Medical School, Sheffield, England
| | - Hannah Dudhill
- Sheffield Medical School, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Jane Shewan
- Research and Development, Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Sue Mason
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Richard A Grünewald
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Markus Reuber
- Academic Neurology Unit, The University of Sheffield, Sheffield, UK
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13
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Ma BB, Bloch J, Krumholz A, Hopp JL, Foreman PJ, Soderstrom CA, Scottino MA, Matsumoto M, Krauss GL. Regulating drivers with epilepsy in Maryland: Results of the application of a United States consensus guideline. Epilepsia 2017; 58:1389-1397. [DOI: 10.1111/epi.13804] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Brandy B. Ma
- Department of Neurology; Johns Hopkins University School of Medicine; Baltimore Maryland U.S.A
| | - John Bloch
- Tulane University School of Medicine; New Orleans Louisiana U.S.A
| | - Allan Krumholz
- Department of Neurology; University of Maryland School of Medicine; Baltimore Maryland U.S.A
| | - Jennifer L. Hopp
- Department of Neurology; University of Maryland School of Medicine; Baltimore Maryland U.S.A
| | - Perry J. Foreman
- Department of Neurology; Sinai Hospital of Baltimore; Baltimore Maryland U.S.A
| | - Carl A. Soderstrom
- Medical Advisory Board; Maryland Motor Vehicle Administration; Glen Burnie Maryland U.S.A
| | - Mary A. Scottino
- Medical Advisory Board; Maryland Motor Vehicle Administration; Glen Burnie Maryland U.S.A
| | - Martha Matsumoto
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
| | - Gregory L. Krauss
- Department of Neurology; Johns Hopkins University School of Medicine; Baltimore Maryland U.S.A
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