Improving neuropsychological seizure lateralization in Spanish-speaking people with epilepsy in the US: The need to account for education and demographic differences

OBJECTIVE

The objective of the study was to investigate the predictive seizure lateralization ability of the Neuropsychological Screening Battery for Hispanics (NeSBHIS) in an optimally, demographically matched cohort of primarily immigrant Spanish-speaking people with epilepsy (PWE) living in the US. Linguistically and culturally appropriate neuropsychological measures for Spanish-speaking people are increasingly needed in the US, especially as this diverse, international population grows. The NeSBHIS was developed to meet this need. Previous studies were inconclusive regarding its utility in epilepsy lateralization with PWE. Sample size and demographic variables, particularly educational levels, which anchor neuropsychological normative data and guide clinical use, limited the conclusions of earlier studies.

METHODS

A retrospective study, the NeSBHIS battery's ability to predict seizure lateralization in a large cohort of Spanish-speaking PWE (n = 108) was conducted using normative data based on refined, smaller education ranges suggested by the author of the NeSBHIS, Pontón.

RESULTS

Regression analysis revealed that four NeSBHIS subtests representing different cognitive domains produced the best model for predicting lateralization: 1) language, 2) attention/mental control, 3) visual memory recall, and 4) verbal memory recall. Prediction accuracy overall was 62% (67.3% for left hemisphere (LH) and 55.8% for right hemisphere (RH)).

CONCLUSION

This study demonstrated the clinical utility of the NeSBHIS in seizure lateralization in a large cohort of Spanish-speaking PWE by analyzing standardized scores based on refined, education-based normative samples. These results also highlight that demographic variables, in particular, education, which varies greatly across Spanish-speaking nations in terms of compulsory educational opportunity and quality, must be accounted for more carefully in clinical and research practice.

Seizures among active component service members, U.S. Armed Forces,2007-2016

Traumatic brain injury (TBI) is a known risk factor for seizures. Evidence also shows that post-traumatic stress disorder (PTSD) is associated with seizures, but the relationship in the absence of TBI remains unclear. This retrospective study spanning 2007-2016 separately quantifies the rates of seizures diagnosed among deployed and non-deployed active component military service members to understand the factors associated with seizures and whether they differ in deployed settings. Higher rates of seizures were associated with service members who were in the Army or Marine Corps; female; black; younger; lower enlisted; in a combat-specific, armor/motor transport, or healthcare occupation; and who had no more than one previous deployment. These associations were similar among both deployed and non-deployed service members. Either a TBI or recent PTSD diagnosis was associated with a 3- to 4-fold increased seizure rate. For service members who had received both diagnoses, seizure rates among the deployed and the non-deployed were two and three times the rates among those with only one of those diagnoses, respectively. If the current results are supported by future investigations, there may be implications for both clinical care and military policy.

Frequency of cardiac events at four years among initially asymptomatic filipinos with the Brugada type 1 electrocardiographic pattern

Brugada type 1 electrocardiographic (ECG) pattern occurs in 0.2% of Filipinos. A knowledge gap exists on the natural course of asymptomatic patients with Brugada type 1 ECG pattern. Most studies that reported cohort event rates were taken from hospitals or referral centers. This is the first cohort from an entire country where the subjects were selected randomly. The objective of this study was to describe the frequency of cardiac events at 4 and 6 years of 7 patients with Brugada type 1 ECG pattern of 3,907 patients previously screened from the general population of the Philippines during the National Nutrition and Health Survey. Personal interviews at year 4 using a structured questionnaire were conducted by 1 of the investigators. Occurrences of major (syncope, seizure, unexplained accidents, sudden death) and minor events in subjects and their first- and second-degree relatives were elicited. Six-year follow-up by text messaging was conducted to ascertain vital status and occurrence of cardiac events. All 7 patients with Brugada type 1 ECG pattern were men. Three of the 7 initially asymptomatic subjects (43%, 95 confidence interval 6 to 80) developed a major cardiac event by the fourth year. Those with events were younger than those without events. All 7 were alive by the sixth year. No additional events were noted between the fourth and sixth years. In conclusion, cardiac events are considerable in initially asymptomatic Filipinos with Brugada type 1 ECG pattern.

Evolution and epilepsy in "Bleak House"

In Charles Dickens's novels, nervous seizures trigger dreamy, clairvoyant episodes in which normally imperceptible connections and relations among events and characters come to light. During such episodes, which the neurologist John Hughlings Jackson would describe as "voluminous" states of consciousness, the boundaries of the self dissolve, and the mind becomes attuned to a range of possible identities or phantom selves. The specters unleashed in this state of nervous "dissolution" haunt Bleak House even as they illuminate relations among members of vastly different social worlds and the great institutional forces that affect the most curious events of the mind.

Seizures in patients with systemic lupus erythematosus: data from LUMINA, a multiethnic cohort (LUMINA LIV)

OBJECTIVE

To examine the predictors of time-to-seizure occurrence and their impact on damage accrual and mortality in LUMINA, a multiethnic (Hispanic, African American and Caucasian) cohort of patients with systemic lupus erythematosus.

METHODS

Seizures were defined as per the American College of Rheumatology (ARC) nomenclature and case definitions for neuropsychiatric lupus syndromes. Factors associated with time-to-seizure occurrence occurring at or after diagnosis (TD) of systemic lupus erythematosus were examined by univariable and multivariable Cox proportional hazard regression analyses. The impact of seizures on damage accrual and mortality was also examined by multivariable analyses after adjusting for variables known to affect these outcomes.

RESULTS

A total of 600 patients were included in these analyses. Of them, 40 (6.7%) developed seizures at or after TD; by multivariable analyses, disease activity and younger age were independent predictors of a shorter time-to-seizure occurrence (HR = 1.10 and 1.04; 95% CI 1.04 to 1.15 and 1.00 to 1.08, p = 0.0004 and 0.0304, respectively) whereas mucocutaneous involvement (HR = 0.34, 95% CI 0.16 to 0.41, p = 0.0039) and hydroxychloroquine use (HR = 0.35, 95% CI 0.15 to 0.80, p = 0.0131) were independent predictors of a longer time-to-seizure occurrence. Seizures were an independent contributor to damage accrual but not to mortality.

CONCLUSIONS

Seizures tend to occur early in the course of systemic lupus erythematosus, and contribute to damage accrual. Younger age and disease activity are independent predictors of a shorter time-to-seizure occurrence; antimalarials appear to have a protective role in seizure occurrence.

Clinical and inheritance profiles of hyperekplexia in Jordan

Hyperekplexia is a rare nonepileptic disorder characterized by excessive startle response to acoustic, visual, or other stimuli. Patients with hyperekplexia are often misdiagnosed as having epilepsy. The presentation modalities, phenotypes, and the modes of inheritance among patients with hyperekplexia from 9 Jordanian families are described. All families were referred with the preliminary diagnosis of uncontrolled seizures with onset of the disease in the neonatal period and with variable and atypical presenting features. The inheritance profile in 4 families was compatible with autosomal recessive and in 1 family with autosomal dominant inheritance. Four families showed sporadic cases of hyperekplexia. This is the first report of a series of patients with hyperekplexia from Jordan. The clinical manifestations show atypical features that have not been previously reported, pointing to the probable broader clinical spectrum of this entity. Recognition of the syndrome allows for prompt proper management and provision of genetic counseling.

[Seizures in foreign newborns due to maternal vitamin-D deficiency]

In a Moroccan male, a Turkish female and a Sudanese male newborn who presented with seizures in the second week of life, hypocalcaemia was found. The hypocalcaemia was caused by neonatal vitamin-D deficiency as a result of maternal vitamin-D deficiency during pregnancy. The vitamin-D deficiency of the mothers was caused by the diminished exposure to sunlight as a result of wearing a veil and the dark pigmentation of the skin. The infants were cured by vitamin-D suppletion. With the increasing numbers of dark-skinned women and women who wear veils in the Dutch population, the group of pregnant women and newborns running a risk of vitamin-D deficiency is becoming larger. Therefore, the risk of hypocalcaemia and vitamin-D deficiency rickets in newborns is also increasing. In newborns with seizures, one should think of the possibility of neonatal vitamin-D deficiency, especially if the mothers belong to the group at risk.

Risk of seizure recurrence after a first unprovoked seizure: a prospective study among Jordanian children

PURPOSE

There is wide variation in the reported recurrence rate after a first unprovoked seizure in children. We investigated the risk of recurrence after a first unprovoked seizure in Jordanian children and the risk factors associated with increased recurrence rate.

METHODS

All consecutive patients aged 3 months-14 years who presented with their first unprovoked seizures between January 1997 and 2000, were included in a prospective study and followed up for 3 years for possible recurrence. Of the patients studied, there was slight male predominance (56.6%) and 55% of them were 2-9 years of age. Generalised seizures were reported in 75% and the remaining 25% had partial seizures. The duration of seizure was 1-4 minutes in 59%. Family history of epilepsy was positive in 31% and parental consanguinity in 32%. The role of these factors in increasing the risk of recurrence was also investigated.

RESULTS

Two hundred sixty-five patients were included in the study and continued follow up for 3 years. Ninety-eight (37%) of them experienced seizure recurrence. Among the predictor factors for recurrence, partial seizure (P = 0.003) and positive family history (P = 0.000) were associated with a statistically significant increased risk. Sex, age, duration of seizure and consanguinity were not associated with increased risk of recurrence.

CONCLUSION

Thirty-seven percent of the children studied experienced a second attack after a first unprovoked seizure over the 3 years follows up period. The risk of recurrence was significantly higher in children with a partial seizure (55%) and among those with a positive family history of epilepsy (59%). Age at first seizure, sex, duration of seizure and consanguinity were not significantly related to the risk of recurrence.

Intra-household relations and treatment decision-making for childhood illness: a Kenyan case study

This study, conducted on the Kenyan coast, assesses the effect of intra-household relations on maternal treatment-seeking. Rural and urban Mijikenda mothers' responses to childhood fevers in the last 2 weeks (n=317), and to childhood convulsions in the previous year (n=43), were documented through survey work. The intra-household relations and decision-making dynamics surrounding maternal responses were explored through in-depth individual and group interviews, primarily with women (n=223). Responses to convulsions were more likely than responses to fevers to include a healer consultation (p<0.0001), and less likely to include the purchase of over-the-counter medications (p<0.0001). Mothers received financial or advisory assistance from others in 71% (n=236) of actions taken outside the household in response to fevers. In-depth interviews suggested that general agreement on appropriate therapy results in relatively few intra-household conflicts over the treatment of fevers. Disputes over perceived cause and appropriate therapy of convulsions, however, highlighted the importance of age, gender and relationship to household head in intra-household relations and treatment decision-making. Although mothers' treatment-seeking preferences are often circumscribed by these relations, a number of strategies can be drawn upon to circumvent 'inappropriate' decisions, sometimes with implications for future household responses to similar syndromes. The findings highlight the complexity of intra-household relations and treatment decision-making dynamics. Tentative implications for interventions aimed at improving the home management of malaria, and for further research, are presented.

Identification of a null allele of CYP2C9 in an African-American exhibiting toxicity to phenytoin

Cytochrome P450 (CYP) 2C9 is the principal enzyme responsible for the metabolism of numerous clinically important drugs. Two polymorphic alleles CYP2C9*2 and CYP2C9*3 have been documented which affect the metabolism and clinical toxicity of drugs such as phenytoin, warfarin, glipizide, and tolbutamide. The present study reports the first example of a null polymorphism in CYP2C9. This mutation dramatically affects the half-life and clinical toxicity of phenytoin. The study subject was a female African-American presented to the emergency department with phenytoin toxicity evidenced by mental confusion, slurred speech, memory loss and the inability to stand. She exhibited extremely poor clearance of phenytoin with an elimination half-life of approximately 13 days. Genotyping studies demonstrated that the patient did not possess any known variant CYP2C9 alleles. Phenytoin is metabolized to a minor extent by the polymorphic CYP2C19, but this individual did not possess any variant CYP2C19 alleles. Sequencing studies revealed that the individual was homozygous for a new CYP2C9 allele (CYP2C9*6) with the deletion of an adenine at base pair 818 of the cDNA. The clearance of phenytoin in this individual is estimated to be approximately 17% of that observed in normal patients. The frequency of this allele was 0.6% (95% confidence limits of 0.1 to 3.5%) in 79 African-Americans and 0% (95% confidence limits of 0 to 1.1%) in 172 Caucasians. The study also demonstrates the severe clinical consequences to patients with a null mutation in CYP2C9 after treatment with normal doses of phenytoin.

Epilepsy and seizure occurrence in a population-based sample of Virginian twins and their families

Epilepsy and seizure occurrence was assessed in a large, population-based sample of Virginian twins and their families. Medical history information on twins and their relatives was collected by questionnaire and used to estimate prevalence of seizures and epilepsy for this sample. Health history information was available on 16,634 twins and their families. Lifetime prevalence of a history of seizures ranged from < 1 to 5%. Concordance rates were larger in monozygotic (MZ) than dizygotic (DZ) pairs overall, however, significant differences between the zygosities were only noted for Caucasian twins. To facilitate interpretation of results, the sample was partitioned into two age groups: 16-35 years and > 35 years of age. In the first age category of twins, significant differences were observed for the following seizure types; epilepsy (0.30 and 0.13, p <0.03), febrile seizures (0.39 and 0.12, p <0.001), and other convulsions/seizures (0.28 and 0.01, p < 0.001). While for twins in the second age category, only the comparison for febrile seizures (0.42 and 0.14, p < 0.001) resulted in a significant difference between zygosities. A family history of seizures was reported in 215 (35.1%) of the 613 seizure positive probands. Increased risk of seizures (1.88-4.64) among relatives of affected versus unaffected individuals was also observed.

Childhood absence epilepsy with tonic-clonic seizures and electroencephalogram 3-4-Hz spike and multispike-slow wave complexes: linkage to chromosome 8q24

Childhood absence epilepsy (CAE), a common form of idiopathic generalized epilepsy, accounts for 5%-15% of childhood epilepsies. To map the chromosomal locus of persisting CAE, we studied the clinical and electroencephalographic traits of 78 members of a five-generation family from Bombay, India. The model-free affected-pedigree member method was used during initial screening with chromosome 6p, 8q, and 1p microsatellites, and only individuals with absence seizures and/or electroencephalogram 3-4-Hz spike- and multispike-slow wave complexes were considered to be affected. Significant P values of .00000-.02 for several markers on 8q were obtained. Two-point linkage analysis, assuming autosomal dominant inheritance with 50% penetrance, yielded a maximum LOD score (Zmax) of 3.6 for D8S502. No other locus in the genome achieved a significant Zmax. For five smaller multiplex families, summed Zmax was 2.4 for D8S537 and 1.7 for D8S1761. Haplotypes composed of the same 8q24 microsatellites segregated with affected members of the large family from India and with all five smaller families. Recombinations positioned the CAE gene in a 3.2-cM interval.

Refractory seizures in a young army cohort

This survey covered male Singapore citizens born in 1974 who were medically screened at the age of 18 years before enlistment for compulsory military service. Suspected epileptics were referred to government hospitals for further management. Out of 20,542 men, there were 121 epileptics, giving a cumulative incidence of 5 per 1000 by age 18 years. We had information on 106 (87%) of these individuals and were able to interview them and review their hospital records. Seventy-three of the 106 (69%) epileptics had generalised seizures while 14 (13%) had refractory seizures. There was no statistically significant racial bias amongst these epileptics. Unprovoked afebrile seizures occurred early in these patients, half of whom had seizures onset before 7 years of age. Nine refractory epileptics had a history of febrile seizures, 4 of which were complex febrile seizures. Magnetic resonance imaging identified mesial temporal sclerosis in 2 patients and a hypothalamic lesion in 1 patient. Computed tomographic scans revealed focal cortical atrophy in 2 patients. Nine other patients had normal imaging studies. Nine out of 14 (64%) patients with refractory epilepsy had partial seizures; 4 (29%) had generalised seizures and 1 (7%) was unclassified. This is in contrast to the distribution of the entire cohort of epileptics studied. Two out of 9 patients with refractory partial seizures (gelastic epilepsy and mesial temporal sclerosis) had undergone surgery while 6 of the other 7 patients refused to consider surgery.

Neonatal seizures in the United States: results of the National Hospital Discharge Survey, 1980-1991

We present nationally representative estimates of neonatal seizure risk by gender, race and geographic region of the United States. National Hospital Discharge Survey data were analyzed for the period 1980-1991. Birth-weight-adjusted risks of neonatal seizures were calculated by the direct method for each gender or race group and for each census region by 4-year intervals. The overall risk of neonatal seizures was 2.84 per 1,000 live births. Risk estimates were consistently higher in low-birth-weight infants (relative risk 3.9). Unadjusted risks were similar across race and gender groups; birth weight adjustment had very little effect. No clear temporal trend was apparent over the 12-year study period. National Hospital Discharge Survey data provide reasonable, although conservative, estimates of neonatal seizure risks nationwide. Underascertainment of neonatal seizures, particularly among sick low-birth-weight infants, is likely due to data collection limitations of the National Hospital Discharge Survey.

Mortality and the acquisition of basic skills by children and adults with severe disabilities

OBJECTIVE

To determine normative data on age-related probabilities of children with severe disabilities acquiring mobility or self-feeding skills, or dying during a 5-year follow-up period.

RESEARCH DESIGN

A 5-year follow-up study of three mutually exclusive subgroups formed on the basis of severe, profound, or suspected levels of retardation and incontinence and the following combinations of feeding and mobility skills.

PARTICIPANTS

The sample was made up of 7836 children and adults distributed among the three subgroups being served in California between January 1981 and December 1985.

MEASUREMENTS/MAIN RESULTS

Subjects who were tube-fed and immobile showed very little likelihood of becoming mobile or feeding themselves and had a high probability of death. Individuals who had some mobility experienced a better outcome.

CONCLUSIONS

After age 6 years, the most probable outcome for children who are immobile and cannot feed themselves is death or no improvement in self-help skills.

Spontaneous hypoparathyroidism: clinical, biochemical and radiological features

The clinical, biochemical and radiological features of spontaneously occurring hypoparathyroidism in 13 patients (mean age 9 years, range 4 months to 20 years) are highlighted. Nine patients presented with a history of generalised seizures and 2 were in acute hypocalcemic crisis at the time of admission. Ocular involvement (corneal opacities, cataract) was present in 3 patients and vitiligo in 1 patient. The serum calcium level was low (mean 5.46 mg/dl, range 5.0-7.2) and serum phosphorus level was high (mean 8.49 mg/dl, range 6-14 mg/dl) in all the patients. Six patients had elevated serum alkaline phosphatase (greater than 20 KAU). Radiological examination revealed osteopenia in 3 patients. Nine patients underwent a head CT scan; 5 had evidence of basal ganglia calcification. The findings of elevated serum alkaline phosphatase and osteopenia are at variance with existing literature and may possibly reflect pre-existing vitamin D deficiency.