Estimating the Prevalence of Treated Epilepsy Using Administrative Health Data and Its Validity: ESSENCE Study

Association between exposure to antibiotics during pregnancy or early infancy and risk of autism spectrum disorder, intellectual disorder, language disorder, and epilepsy in children: population based cohort study

OBJECTIVE

To evaluate the association between antibiotic use during pregnancy or early infancy and the risk of neurodevelopmental disorders in children.

DESIGN

Nationwide population based cohort study and sibling analysis.

SETTING

Korea's National Health Insurance Service mother-child linked database, 2008-21.

PARTICIPANTS

All children live born between 2009 and 2020, followed up until 2021 to compare those with and without antibiotic exposure during pregnancy or early infancy (first six months of life).

MAIN OUTCOMES MEASURES

Autism spectrum disorder, intellectual disorder, language disorder, and epilepsy in children. After 1:1 propensity score matching based on many potential confounders, hazard ratios with 95% confidence interval were estimated using Cox proportional hazard models. A sibling analysis additionally accounted for unmeasured familial factors.

RESULTS

After propensity score matching, 1 961 744 children were identified for the pregnancy analysis and 1 609 774 children were identified for the early infancy analysis. Although antibiotic exposure during pregnancy was associated with increased risks of all four neurodevelopmental disorders in the overall cohort, these estimates were attenuated towards the null in the sibling analyses (hazard ratio for autism spectrum disorder 1.06, 95% confidence interval 1.01 to 1.12; intellectual disorder 1.00, 0.93 to 1.07; language disorder 1.05, 1.02 to 1.09; and epilepsy 1.03, 0.98 to 1.08). Likewise, no association was observed between antibiotic exposure during early infancy and autism spectrum disorder (hazard ratio 1.00, 0.96 to 1.03), intellectual disorder (1.07, 0.98 to 1.15), and language disorder (1.04, 1.00 to 1.08) in the sibling analyses; however, a small increased risk of epilepsy was observed (1.13, 1.09 to 1.18). The results generally remained consistent across several subgroup and sensitivity analyses, except for slightly elevated risks observed among children who used antibiotics during very early life and those who used antibiotics for more than 15 days.

CONCLUSIONS

In this large cohort study, antibiotic exposure during pregnancy or early infancy was not associated with an increased risk of autism spectrum disorder, intellectual disorder, or language disorder in children. However, elevated risks were observed in several subgroups such as children using antibiotics during very early life and those with long term antibiotic use, which warrants attention and further investigation. Moreover, antibiotic use during infancy was modestly associated with epilepsy, even after control for indications and familial factors. When prescribing antibiotics to pregnant women and infants, clinicians should carefully balance the benefits of use against potential risks.

On the Dependence of the Critical Success Index (CSI) on Prevalence

The critical success index (CSI) is an established metric used in meteorology to verify the accuracy of weather forecasts. It is defined as the ratio of hits to the sum of hits, false alarms, and misses. Translationally, CSI has gained popularity as a unitary outcome measure in various clinical situations where large numbers of true negatives may influence the interpretation of other, more traditional, outcome measures, such as specificity (Spec) and negative predictive value (NPV), or when unified interpretation of positive predictive value (PPV) and sensitivity (Sens) is needed. The derivation of CSI from measures including PPV has prompted questions as to whether and how CSI values may vary with disease prevalence (P), just as PPV estimates are dependent on P, and hence whether CSI values are generalizable between studies with differing prevalences. As no detailed study of the relation of CSI to prevalence has been undertaken hitherto, the dataset of a previously published test accuracy study of a cognitive screening instrument was interrogated to address this question. Three different methods were used to examine the change in CSI across a range of prevalences, using both the Bayes formula and equations directly relating CSI to Sens, PPV, P, and the test threshold (Q). These approaches showed that, as expected, CSI does vary with prevalence, but the dependence differs according to the method of calculation that is adopted. Bayesian rescaling of both Sens and PPV generates a concave curve, suggesting that CSI will be maximal at a particular prevalence, which may vary according to the particular dataset.

A ResNet-LSTM hybrid model for predicting epileptic seizures using a pretrained model with supervised contrastive learning

In this paper, we propose a method for predicting epileptic seizures using a pre-trained model utilizing supervised contrastive learning and a hybrid model combining residual networks (ResNet) and long short-term memory (LSTM). The proposed training approach encompasses three key phases: pre-processing, pre-training as a pretext task, and training as a downstream task. In the pre-processing phase, the data is transformed into a spectrogram image using short time Fourier transform (STFT), which extracts both time and frequency information. This step compensates for the inherent complexity and irregularity of electroencephalography (EEG) data, which often hampers effective data analysis. During the pre-training phase, augmented data is generated from the original dataset using techniques such as band-stop filtering and temporal cutout. Subsequently, a ResNet model is pre-trained alongside a supervised contrastive loss model, learning the representation of the spectrogram image. In the training phase, a hybrid model is constructed by combining ResNet, initialized with weight values from the pre-trained model, and LSTM. This hybrid model extracts image features and time information to enhance prediction accuracy. The proposed method's effectiveness is validated using datasets from CHB-MIT and Seoul National University Hospital (SNUH). The method's generalization ability is confirmed through Leave-one-out cross-validation. From the experimental results measuring accuracy, sensitivity, and false positive rate (FPR), CHB-MIT was 91.90%, 89.64%, 0.058 and SNUH was 83.37%, 79.89%, and 0.131. The experimental results demonstrate that the proposed method outperforms the conventional methods.

Prevalence, demographic and spatial distribution of treated epilepsy in France in 2020: a study based on the French national health data system

BACKGROUND

Although still incomplete, the epidemiology of epilepsy shows substantial variations in the burden of the condition according to demographic, social and territorial characteristics. This study aimed to estimate the prevalence of treated epilepsy and to investigate its demographic and spatial distribution in 2020 in France, a country where the nationwide epidemiological situation of the condition remains largely unknown.

METHODS

We used the French national health data system, which covers nearly the entire population residing in France (over 67 million of inhabitants in metropolitan and overseas departments). Prevalent cases were identified using long-term disease status, hospitalisation for epilepsy (ICD-10 codes G40 or G41), and reimbursements for antiseizure medications and electroencephalograms.

RESULTS

In 2020, we identified 685,122 epilepsy cases, corresponding to an overall prevalence of 10.2 per 1000 inhabitants [95% confidence interval 10.1-10.2], with similar rates in men and women. Estimates were found to increase with age, with an accelerated rise in the second half of the life, which occurred earlier in men than in women. We observed a monotonic gradient of variation with socio-economic deprivation (in non-military metropolitan subjects aged 18-54 years) as well as territorial heterogeneity, with the mountainous centre of France as well as some French overseas departments having the highest prevalence.

CONCLUSIONS

Our results revise upwards the estimation of epilepsy prevalence in France, showing that it now ranks among the highest in developed countries. Our study also confirms the important socio-territorial heterogeneity of the condition that reflects health inequalities in this country.

Efficacy and Safety of Brivaracetam in Persons With Epilepsy in a Real-World Setting: A Prospective, Non-Interventional Study

BACKGROUND AND AIM

Epilepsy stands out as one of the most prevalent neurological conditions. Brivaracetam (BRV) is a noteworthy antiseizure medication (ASM) distinguished by its pronounced and selective interaction with the synaptic vesicle protein 2A (SV2A) within the brain. Prior investigations, including regulatory trials, post-marketing assessments, and comparative meta-analyses, have consistently underscored BRV's equivalency in efficacy and superior tolerability when pitted against other antiseizure drugs. This study aimed to evaluate the effectiveness, safety, and acceptability of BRV in treating epileptic patients in the Pakistani population.

METHODS

This prospective observational study, conducted in Pakistan from February to December 2022, employed a non-probability consecutive sampling technique. This study included 368 adult patients diagnosed with epilepsy, with a focus on those aged 18 and above experiencing focal seizures. Demographic data, clinical history, seizure types, and epilepsy profiles were recorded. Patients were administered BRV (Brivera; manufactured by Helix Pharma Pvt Ltd., Sindh, Pakistan) monotherapy therapy under physician guidance and followed up for three months. The study assessed changes in seizure frequency, side effects, and drug resistance at baseline, 14th day, and 90th day. Safety aspects were monitored, including documenting any adverse effects associated with BRV therapy.

RESULTS

A total of 368 epileptic patients were included in this study, of which 287 (61.3%) were males and 181 (38.7%) were females. The mean age was 32.91±17.11 years. The mean number of seizures at the baseline visit was 5.74±6.21, at 14 days was 2.89±3.84 and at 90 days was 1.73±5.01 (p<0.001). Overall, a more than 50% reduction in seizure episodes was achieved in 178 (56.3%) patients at day 90, and less than 50% reduction in seizure episodes was achieved by 95 (26.8%) patients on Day 14, with a highly significant association between them (p<0.001). Among 316 patients, only 41 (4.4%) of all BRV-treated patients experienced adverse events; Of these 41 patients, 17 (41.7%) reported dizziness and 14(34.2%) reported behavioral issues.

CONCLUSIONS

Epileptic patients receiving BRV demonstrated a substantial reduction of greater than 50% seizure episodes at the end of follow-up visits. Moreover, BRV exhibited fewer adverse effects in individuals with epilepsy.

Anti-seizure medication prescription in epilepsy patients in South Korea: A seven-year population-based retrospective cohort study

BACKGROUND AND OBJECTIVES

This study aimed to explore the natural history of patients with epilepsy using overall antiseizure-medication (ASM) treatment patterns on a nationwide scale in South Korea.

METHODS

We investigated a retrospective longitudinal cohort of patients with epilepsy in South Korea using nationwide data from the Korean National Health Information Database of the Health Insurance and Review Assessment Service between January 1st, 2009, and December 31st, 2018. Histories of each patient's ASM prescription were followed for up to 7 years from the index date, the first observed date of ICD-10 epilepsy diagnosis codes with at least one ASM prescription.

RESULTS

Of 82,390 incident patients analyzed, ten thousand and fifty-nine were followed up to seven years, and nearly 60% of them discontinued the ASM(s). The proportion of patients with possible drug-resistant epilepsy (DRE), who experience three or more types of ASMs, gradually increased, reaching approximately 8.8% of the total number of patients in the seventh year (6.45% for adults, 21.8% for children). The duration of progression for half of the patients with possible DRE was 1.29 years for children, 1.79 years for adults, and 1.62 years for mixed-age patients. However, even in the sixth year, 72 cases progressed to possible DRE, and 6 cases with possible DRE discontinued ASMs in the next year, showing a dynamic process.

DISCUSSION

Our population-based study showed the dynamic changes of anti-seizure medication prescription in epilepsy patients with real-world data, which slowly stabilizes over years after the first diagnosis of epilepsy.

Premature Mortality and Causes of Death Among People With Epilepsy: A Nationwide Population-Based Incident Cohort Study

BACKGROUND AND OBJECTIVES

People with epilepsy (PWE) are at risk of premature death with considerable variability according to the study population. We aimed to estimate the risk and causes of death in PWE according to age, disease severity, disease course, comorbidities, and socioeconomic status in Korea.

METHODS

We conducted a nationwide population-based retrospective cohort study using the National Health Insurance database linked with the national death register. Newly treated PWE from 2008 to 2016 who were identified by antiseizure medication (ASM) prescriptions and diagnostic codes for epilepsy/seizure were included and observed until 2017. We assessed all-cause and cause-specific crude mortality rates and standardized mortality ratios (SMRs).

RESULTS

Among 138,998 PWE, 20,095 deaths were identified, and the mean follow-up period was 4.79 years. The SMR was 2.25 in the overall group of PWE, with a higher value in the younger age group at diagnosis and a shorter time interval after diagnosis. The SMR in the monotherapy group was 1.56, while that in the group with 4 or more ASMs was 4.93. PWE without any comorbidities had an SMR of 1.61. PWE who were rural residents had a higher SMR than those who were urban residents (2.47 vs 2.03, respectively). The causes of death among PWE were cerebrovascular disease (18.9%, SMR 4.50), malignant neoplasms outside the CNS (15.7%, SMR 1.37), malignant neoplasms of the CNS (6.7%, SMR 46.95), pneumonia (6.0%, SMR 2.08), and external causes (7.2%, SMR 2.17), including suicide (2.6%, SMR 2.07). Epilepsy itself and status epilepticus accounted for 1.9% of the overall death. The excess mortality associated with pneumonia and external causes was persistently high, whereas the excess mortality associated with malignancy and cerebrovascular diseases tended to decrease with increasing time since diagnosis.

DISCUSSION

This study showed excess mortality in PWE, even in those without comorbidities and those receiving monotherapy. Regional disparities and sustained risks of deaths from external causes over 10 years imply potential points of intervention. In addition to active control of seizures, education about injury prevention, monitoring for suicidal ideation, and efforts to improve accessibility to epilepsy care are all required to reduce mortality.

Trends of Epilepsy-Related Mortality in South Korea

BACKGROUND AND PURPOSE

Epilepsy increases the risk of death in affected individuals of any age. We aimed to determine the mortality caused by epilepsy and its time trends in Korea.

METHODS

We obtained population and cause of death data between 1993 and 2019 from Statistics Korea. We identified death caused by epilepsy or status epilepticus. We calculated the crude mortality rate (CMR), age-specific mortality rate, age-standardized mortality rate (ASMR, corresponding to epilepsy-related deaths per 100,000 persons in the general population), and the proportional mortality (PM, corresponding to the proportion of epilepsy-related deaths among all-cause deaths).

RESULTS

In 2019, 471 deaths were caused by epilepsy (CMR=0.92), accounting for 0.16% of all deaths in that year. The age-specific mortality rate increased with age, up to 7.01% among individuals aged 80 years and older, while the PM was the highest (3.80%) among individuals aged 5-14 years, which decreased with age. Between 1993 and 2019, the CMR, ASMR, and PM peaked in 2002, and the CMR then rebounded after the trough in this trend in 2011 while the ASMR continued to decrease, and the PM became relatively stable from 2011. Starting in 2005, the age-specific mortality rate for epilepsy had an increasing tendency over time among those aged 75 years or older, and a decreasing tendency in the younger age groups.

CONCLUSIONS

A declining tendency of mortality from epilepsy was found in the overall population of Korea over recent decades. However, epilepsy is a notable cause of death in children, and epilepsy-related mortality is increasing in the elderly population.

Perampanel as First Add-On Therapy in Patients with Focal-Onset Seizures in the FAME Trial: <i>Post hoc</i> Analyses of Efficacy and Safety Related to Maintenance Dose and Background Antiepileptic Drug Therapy

Background and Purpose: FAME (Fycompa^® as first Add-on to Monotherapy in patients with Epilepsy; NCT02726074), a previously reported single-arm, phase IV study, showed that perampanel improved seizure control as first add-on to failed anti-seizure medication (ASM) monotherapy in 85 South Korean patients aged ≥12 years with focal-onset seizures (FOS) with/without focal to bilateral tonic-clonic seizures. We present results of three <i>post hoc</i> analyses of FAME that further assessed the efficacy and safety of perampanel.Methods: Patients were stratified by low- (4, 6 mg/day) versus high- (8, 10, 12 mg/day) dose maintenance perampanel, perampanel added to first- versus second-line ASM monotherapy, and concomitant background ASM monotherapy and perampanel dose. The primary endpoint was the proportion of patients with a ≥50% reduction in total seizure frequency during the 24-week maintenance period. Safety was assessed by the descriptive incidence of treatment-emergent adverse events (TEAEs).Results: In <i>post hoc</i> analyses, 50% responder rates were significantly higher for low- versus high-dose maintenance perampanel (88.6% vs. 40.0%; <i>p</i><0.001) and when added to first- versus second-line ASM monotherapy (83.5% vs. 33.3%; <i>p</i>=0.013). By concomitant background ASM and perampanel maintenance dose, 50% responder rates were 100% for perampanel 4 mg/day added to carbamazepine, oxcarbazepine, lamotrigine, or valproic acid, and 85% when added to levetiracetam. Add-on perampanel improved 75% and seizure-free responder rates, and median percent changes from baseline seizure frequency per 28 days. Perampanel was well tolerated when added to ASM monotherapy, with dizziness being the most common TEAE.Conclusions: <i>Post hoc</i> analyses of FAME provide supportive data for the use of perampanel as an effective and well-tolerated first add-on treatment to a broad spectrum of ASM monotherapies in patients with FOS.

Risk of COVID-19 Infection and of Severe Complications Among People With Epilepsy: A Nationwide Cohort Study

OBJECTIVE

To evaluate whether patients with epilepsy were more susceptible to coronavirus disease 2019 (COVID-19) infection and at greater risk of severe complications when infected with COVID-19 when compared with patients without epilepsy.

METHODS

We included participants who underwent at least one SARS-CoV-2 real-time reverse transcription polymerase chain reaction test between Jan 1 and June 4, 2020 from the Korean nationwide COVID-19 dataset. Epilepsy was defined according to the presence of diagnostic code in health claims data prior to the COVID-19 diagnosis. To investigate the association between epilepsy and the susceptibility or severe complications of COVID-19, a 1:6 ratio propensity score matching (PSM) and logistic regression analysis were performed. Severe complications with COVID-19 infection were defined as a composite of the incidence of mechanical ventilation, intensive care unit admission, and death within two months after COVID-19 diagnosis.

RESULTS

Among 212,678 study participants who underwent COVID-19 test, 3,919 (1.8%) had a history of epilepsy. After PSM, there was no significant difference in COVID-19 PCR positivity according to epilepsy history [odds ratio (OR): 0.86, 95% confidence interval (CI) 0.67-1.11]. Of the 7,713 individuals with confirmed COVID-19 infection, 72 (0.9%) had a history of epilepsy. Among the COVID-19 patients, the severe complications occurred in 444 (5.8%) individuals. After PSM, the presence of epilepsy was associated with occurrence of severe complications after COVID-19 infection [OR: 2.05, 95% CI: 1.04-4.04]. Mortality following COVID-19 infection did not differ according to the presence of epilepsy history [OR: 1.55, 95% CI: 0.65-3.70].

CONCLUSIONS

The presence of epilepsy was not associated with increased susceptibility to COVID-19 infection or mortality related to the infection. However, there was an increased risk of severe complications with COVID-19 in patients with epilepsy; therefore, careful management and monitoring may be necessary.

Association between tramadol use and seizures: A nationwide case-case-time-control study

PURPOSE

Tramadol may lower the seizure threshold; however, there is no conclusive evidence to confirm this. This study aimed to determine whether the use of tramadol is associated with the occurrence of seizures.

METHODS

We conducted a case-case-time-control (CCTC) study by identifying patients who had received tramadol and seizure diagnosis in a nationwide healthcare database in South Korea between 2003 and 2015. Each case was matched for age and sex to one future case to adjust for time trends in exposure without selection bias from the use of an external control group. The use of tramadol was assessed during a risk period of 1-30 days, and two reference periods, 61-90 days and 91-120 days, preceding the first diagnosis of seizures. We calculated the adjusted odds ratio (aOR) by dividing the OR in cases (case-crossover) by the OR in future cases (control-crossover). We performed a dose-response analysis using the average daily dose.

RESULTS

We identified 2,523 incident cases with matched future cases (mean age, 45.4 years; 50% men). The aOR for seizure with tramadol use was 0.94 (95% confidence interval [CI], 0.98-1.43) in the CCTC analysis, with a case-crossover OR of 1.19 (0.98-1.43) and control-crossover OR of 1.27 (1.03-1.56). The dose-response analysis showed a similar trend in the main analysis: a low-dose aOR of 0.80 (0.50-1.28) and a high-dose aOR of 0.92 (0.41-2.11).

CONCLUSION

We could not identify a significant association between transient use of tramadol and incidence of seizures in clinical practice.

Evaluation of persistence and healthcare utilization in patients treated with anti-seizure medications as add-on therapy: A nationwide cohort study in South Korea

OBJECTIVE

To compare medication adherence and healthcare utilization among patients who were treated with anti-seizure medications (ASMs) as first add-on to monotherapy for epilepsy using the national health insurance claims data.

METHODS

A retrospective observational cohort study was conducted using the Korean National Health Insurance claims data. Patients who received ASM as first add-on to monotherapy during January 2017 to February 2018 were included. The selected patients were followed up for 12 months to evaluate persistence, adherence, and healthcare resource utilization.

RESULTS

In total, 4277 patients who received ASM as first add-on to monotherapy for epilepsy were enrolled. The mean treatment duration of add-on ASM was 296.6 ± 108.6 days during the 1-year follow-up period and 64.3% of the total population were persistent on the add-on ASM at 365 days from the index date. The mean medication possession ratio (MPR) was 90.3 ± 23.7 and the proportion of adherent patients with ≥80% MPR was 79.3%. Lamotrigine (LTG), levetiracetam (LEV), oxcarbazepine (OXC), and perampanel (PER) groups showed significantly higher persistence and adherence than carbamazepine (CBZ), topiramate (TPM), and valproate (VAL) groups during the 1-year follow-up period. Significant differences in length of stays, total hospitalization cost, outpatient visit cost, and emergency cost were shown between ASM groups and LTG, LEV, OXC, and PER showed relatively low utilization and cost.

CONCLUSIONS

Better adherence was observed in LTG, LEV, OXC, and PER groups than in CBZ, TPM, and VAL groups. Healthcare utilization and related costs showed significant difference between ASM groups.

Trends in Prescribing of Antiseizure Medications in South Korea: Real-World Evidence for Treated Patients With Epilepsy

Background and Purpose

We investigated the trends in the prescribing of antiseizure medication (ASM) over a 9-year period, and provide real-world data regarding ASM prescriptions of patients with epilepsy in South Korea.

Methods

This study used data in the Korean National Health Information Database for the period from 2009 to 2017. We included 18 oral ASMs, which were classified into older and newer ASMs based on them first becoming available on the market before or after 1991, respectively. The annual trends in ASM prescriptions were plotted over the 9-year study period, and changes in these trends were evaluated as average annual percentage changes (AAPCs) using Poisson regression. Age- and sex-stratified analyses were also conducted.

Results

Overall, the proportion of prescriptions involving polytherapy with three or more ASMs increased from 10.08% in 2009 to 10.99% in 2017 (AAPC=0.9%, p<0.001) over the 9-year study period. Among monotherapies, although valproate (VPA) was the most frequently prescribed ASM, the prescription rate of levetiracetam (LEV) steadily increased regardless of age and sex over the study period. The monotherapy prescription trends differed depending on age and sex. In the five most frequently used ASM combination regimens, the prescription rates of VPA/LEV, LEV/oxcarbazepine, and LEV/lamotrigine regimens showed increasing tendencies. In contrast, prescription rates for all combined regimens of older ASMs declined over time in all age groups.

Conclusions

This is the first epidemiological study of the changes in prescription trends for ASM in South Korea based on nationwide data from 2009 to 2017. We found progressive increases in the use of newer ASMs for both monotherapy and duotherapy, and for polytherapy with three or more ASMs over the 9-year study period.

Increasing Trends in the Incidence and Prevalence of Epilepsy in Korea

BACKGROUND AND PURPOSE

There have been few reports on recent trends in the occurrence of epilepsy. The aim of this study was to estimate the incidence and prevalence of epilepsy and analyze their annual trends in Korea over the period 2009-2017.

METHODS

This nationwide population-based study was carried out using the National Health Insurance Service of Korea database. A prevalent case was defined as one of a patient receiving a prescription of anticonvulsants under the diagnostic codes for epilepsy or seizure. An incident case was ascertained by confirming the absence of any epilepsy-related diagnostic codes and anticonvulsant prescription for 2 years or more before the operational definition for a prevalent case was met. Alternative operational definitions for epilepsy were tested. The temporal trends of the incidence and prevalence of epilepsy were analyzed using a Poisson regression model, and are expressed as average annual percentage changes (AAPCs).

RESULTS

The incidence of epilepsy increased from 28.7/100,000 persons in 2009 to 35.4/100,000 persons in 2017. The prevalence increased gradually from 3.4/1,000 persons in 2009 to 4.8/1,000 persons in 2017. These increasing trends were more evident among elderly subjects aged ≥75 years and in those who had codes for epilepsy or seizure as an additional diagnosis. Age standardization revealed a less prominent but still increasing trend in both incidence (AAPC=0.48%) and prevalence (AAPC=3.11%).

CONCLUSIONS

There have been increasing trends in both the prevalence and incidence of epilepsy in Korea between 2009 and 2017. This finding appears to be related to societal aging and the high incidence of symptomatic epilepsy in the elderly population.

Treatment of epilepsy in adults: Expert opinion in South Korea

OBJECTIVE

The aim of this study was to gather the expert opinions of Korean epileptologists regarding the treatment of adult patients with epilepsy.

METHODS

A total of 42 neurologists who specialized in epilepsy were surveyed. They completed an online questionnaire describing multiple patient scenarios. Using these scenarios, they evaluated treatment strategies and gave their preference for specific antiepileptic drugs (AEDs) used to treat genetically mediated generalized epilepsy and focal epilepsy.

RESULTS

Initial AED monotherapy, followed by a second form of alternative monotherapy or an add-on combination therapy, was the preferred treatment strategy. The experts reached consensus for 87.2% of the items. The most commonly selected AEDs for the initial monotherapy for patients with generalized epilepsy were levetiracetam or valproate. For those with focal epilepsy, levetiracetam, oxcarbazepine, or lamotrigine were the most popular selections. Ethosuximide was the treatment of choice only for patients with generalized epilepsy with prominent absence seizures. Levetiracetam was preferred as an add-on therapy for both generalized and focal epilepsy. For special populations of patients, such as elderly adults or those with comorbid diseases, levetiracetam or lamotrigine was selected as the treatment of choice.

CONCLUSION

Most of the survey results were in accordance with the US expert opinion survey published in 2016. This survey can assist clinicians in making clinical decisions when treating individual adult patients with epilepsy.

Refining General Principles of Antiepileptic Drug Treatments for Epilepsy

Antiepileptic drugs (AEDs) are the primary treatment strategy for epilepsy. As the use of AEDs has become more widespread and diverse over the past century, it has become necessary to refine the associated prescription strategies. This prompted the Drug Committee of the Korean Epilepsy Society to perform a systemic review of both international and domestic guidelines as well as literature related to medical treatment of epilepsy, and prepared a series of reviews to provide practical guidelines for clinicians to follow. This article is the first in a series on AED treatments for epilepsy in South Korea.

Medication self-management and the quality of discharge education among parents of children with epilepsy

INTRODUCTION

Medication self-management is critical among children with epilepsy. In the present study, we aimed to investigate the perceptions regarding the quality of discharge education among parents of children with epilepsy. In addition, we assessed the impact of their perceptions on medication self-management. The quality of discharge education was assessed in two parts: content and delivery. The quality of delivery was defined as the manner in which nurses teach the content regarding hospital discharge.

METHODS

Forty-seven parents of children with epilepsy completed the questionnaires regarding demographics, the quality of discharge education, and medication self-management (the Quality of Discharge Teaching Scale and the Pediatric Epilepsy Medication Self-Management Questionnaire).

RESULTS

Parent-reported quality of discharge education was positively correlated with medication self-management (r = 0.305; p = .037). Parent-reported quality of delivery, but not the amount of content, was positively correlated with medication self-management (r = 0.347; p = .017).

CONCLUSIONS

These data suggest that efforts to improve medication self-management among children with epilepsy should include strategies to develop teaching skills among nurses delivering the discharge education.

Changes in the Diagnostic Efficiency of Thyroid Fine-Needle Aspiration Biopsy during the Era of Increased Thyroid Cancer Screening in Korea

Purpose

The volume of thyroid cancer screening and subsequent thyroid fine-needle aspiration (FNA) have rapidly increased in South Korea. We analyzed the thyroid cancer diagnoses/thyroid FNA ratio according to the annual number of FNA to evaluate changes in the diagnosticefficiency of FNA.

Materials and Methods

This was a nationwide population-based retrospective cohort study. The overall thyroid cancer diagnoses/thyroid FNA ratio and annual incremental thyroid cancer diagnoses/incremental thyroid FNA ratio were indirectly calculated using data obtained from the Korea Central Cancer Registry database and the Korean National Health Insurance Service claims database from 2004 to 2012. Pearson correlation analyses were performed to evaluate the strength of linear associations between variables.

Results

The number of thyroid FNA increased from 28,596 to 177,805 (6.2-fold increase) from 2004 to 2012. The overall thyroid cancer diagnoses/thyroid FNA ratio decreased from 36.5% in 2004 to 25.1% in 2012 and was negatively correlated to the number of FNA (R=‒0.977, p < 0.001). The annual incremental thyroid cancer diagnoses/incremental thyroid FNA ratios (range, 15.3% to 30.7%) were always lower than the overall thyroid cancer diagnoses/thyroid FNA ratio in each year and also worsened according to the increase in the number of FNA (R=‒0.853, p=0.007).

Conclusion

The diagnostic performance of both overall and annual incremental thyroid FNA worsened, whereas the number of thyroid FNA procedures increased. More sophisticated indications for FNA are required to improve its diagnostic efficiency, considering the increased burden of screening-detected thyroid nodules.

An estimation of global volume of surgically treatable epilepsy based on a systematic review and meta-analysis of epilepsy

OBJECTIVEEpilepsy is one of the most common neurological disorders, yet its global surgical burden has yet to be characterized. The authors sought to compile the most current epidemiological data to quantify global prevalence and incidence, and estimate global surgically treatable epilepsy. Understanding regional and global epilepsy trends and potential surgical volume is crucial for future policy efforts and resource allocation.METHODSThe authors performed a systematic literature review and meta-analysis to determine the global incidence, lifetime prevalence, and active prevalence of epilepsy; to estimate surgically treatable epilepsy volume; and to evaluate regional trends by WHO regions and World Bank income levels. Data were extracted from all population-based studies with prespecified methodological quality across all countries and demographics, performed between 1990 and 2016 and indexed on PubMed, EMBASE, and Cochrane. The current and annual new case volumes for surgically treatable epilepsy were derived from global epilepsy prevalence and incidence.RESULTSThis systematic review yielded 167 articles, across all WHO regions and income levels. Meta-analysis showed a raw global prevalence of lifetime epilepsy of 1099 per 100,000 people, whereas active epilepsy prevalence is slightly lower at 690 per 100,000 people. Global incidence was found to be 62 cases per 100,000 person-years. The meta-analysis predicted 4.6 million new cases of epilepsy annually worldwide, a prevalence of 51.7 million active epilepsy cases, and 82.3 million people with any lifetime epilepsy diagnosis. Differences across WHO regions and country incomes were significant. The authors estimate that currently 10.1 million patients with epilepsy may be surgical treatment candidates, and 1.4 million new surgically treatable epilepsy cases arise annually. The highest prevalences are found in Africa and Latin America, although the highest incidences are reported in the Middle East and Latin America. These regions are primarily low- and middle-income countries; as expected, the highest disease burden falls disproportionately on regions with the fewest healthcare resources.CONCLUSIONSUnderstanding of the global epilepsy burden has evolved as more regions have been studied. This up-to-date worldwide analysis provides the first estimate of surgical epilepsy volume and an updated comprehensive overview of current epidemiological trends. The disproportionate burden of epilepsy on low- and middle-income countries will require targeted diagnostic and treatment efforts to reduce the global disparities in care and cost. Quantifying global epilepsy provides the first step toward restructuring the allocation of healthcare resources as part of global healthcare system strengthening.

Validity of health insurance data to identify people with epilepsy

BACKGROUND

Large administrative databases may prove useful to assess epilepsy-related comorbidity and mortality. Despite their increased use, their validity as data source in epilepsy is yet under-ascertained.

METHODS

Achmea is a large Dutch health insurance company covering about 25% of the population. We performed a retrospective cohort study using data from the Achmea Health Insurance Database (AHID) over the period 2006-2009. To assess the validity of epilepsy codes in the AHID, we randomly invited 1000 individuals (age 18-75 years insured by Achmea), attending an epilepsy centre or a district hospital during 2006-2009, to participate. Informed consent was provided and 293 were eligible for inclusion. We compared the diagnostic codes for epilepsy in AHID with the diagnosis in their case-notes (reference standard). As additional measure of validity, we compared prevalence of epilepsy codes in AHID (based on anonymized data of all 26.297 subjects with this code in AHID) with epilepsy prevalence rates in the general Dutch population to estimate an age-specific standardized prevalence ratio.

RESULTS

We identified 293 participants with an epilepsy code in AHID. The majority (278) of them had a definite or possible diagnosis of epilepsy in the case-notes; i.e. a positive predictive value of 0.95 (95% CI 0.92-0.97). The overall prevalence of epilepsy codes in the AHID was slightly higher than the putative prevalence in the general Dutch population (7.4/1.000 vs. 6.8/1.000) with a Standardized Prevalence Ratio of 1.08 (95% CI: 1.08-1.09).

CONCLUSIONS

Our findings demonstrate the validity of AHID data for a diagnosis of epilepsy and confirm previous work on using administrative data for epilepsy research.

Headache and Epilepsy

Headache, especially migraine, has long been associated with epilepsy, based on the common clinical features of these disorders. Both migraine and epilepsy have a genetic predisposition and share common pathophysiological mechanisms including an imbalance between excitatory and inhibitory factors that result in spells of altered brain function and autonomic symptoms. There are well-documented reports on the headache as a sole manifestation of epileptic seizure and headache is commonly associated with as preictal, ictal, and postictal symptoms in epilepsy patients. In addition, migraine and epilepsy are frequently described as highly comorbid conditions and several antiepileptic drugs are used for the patients with migraine as well as epilepsy. In the present review, we briefly discuss the connection between headache and epilepsy in various aspects, including classification, clinical features, epidemiology, genetics, pathophysiology, and treatment.