Patient-Level and Center-Level Factors Associated with Required Predonation Weight Loss among Obese Living Kidney Donors

Key Points

Among obese living kidney donors, year of donation, preoperative body mass index, hypertension, and center percent of living kidney donor transplants were associated with required predonation weight loss. There were no significant differences in the likelihood of predonation weight loss requirement by race, sex, or age or by markers of preoperative metabolic dysfunction.

Background

The proportion of overweight/mildly obese living kidney donors (OLKDs) has increased in the past few decades, with significant center variation in the body mass index (BMI) of LKDs. The purpose of this study was to examine factors associated with required predonation weight loss among OLKDs (BMI, ≥30 kg/m2).

Methods

This retrospective cohort study surveyed 1097 OLKDs (1979–2020) (mean BMI, 33 kg/m2) about their donation experience. Bivariate analyses compared donor demographic and center characteristics by whether the donor reported predonation weight loss requirement. Generalized estimating equations with logit link were used to estimate marginal effects of patient-level and center-level factors. Multiple imputation using chained equations was implemented to account for missing values.

Results

Of 1097 OLKDs surveyed, 340 (31.0%) reported predonation weight loss requirement. Donors with a predonation weight loss requirement had slightly higher predonation BMIs and donated in more recent years at centers performing a lower percentage of living donor nephrectomies and with a lower median BMI. In multivariable logistic regression analysis, we observed transplant year (odds ratio [OR], 1.04 per year donation; 95% confidence interval [CI], 1.01 to 1.07; P = 0.005), preoperative BMI (OR, 1.16; 95% CI, 1.05 to 1.28; P < 0.01), preoperative hypertension (OR, 1.61; 95% CI, 1.08 to 2.40; P = 0.02), and center percentage of living donor kidney transplants (OR, 0.99; 95% CI, 0.98 to 1.00; P = 0.02) as significantly associated with a predonation weight loss requirement. The study found no differences in the likelihood of predonation weight loss requirement by race, sex, age, preoperative creatinine, preoperative metabolic dysfunction, or center-level median BMI of living donors.

Conclusions

These results suggest that both center-level and patient-level factors influence whether OLKDs are required to lose weight before donation. Future study is needed to determine whether predonation weight loss is associated with improved long-term postdonation outcomes.

Change in Body Mass Index and Attributable Risk of New-Onset Hypertension Among Obese Living Kidney Donors

OBJECTIVE

To examine whether body mass index (BMI) changes modify the association between kidney donation and incident hypertension.

BACKGROUND

Obesity increases hypertension risk in both general and living kidney donor (LKD) populations. Donation-attributable risk in the context of obesity, and whether weight change modifies that risk, is unknown.

METHODS

Nested case-control study among 1558 adult LKDs (1976-2020) with obesity (median follow-up: 3.6 years; interquartile range: 2.0-9.4) and 3783 adults with obesity in the Coronary Artery Risk Development in Young Adults (CARDIA) and Atherosclerosis Risk in Communities (ARIC) studies (9.2 y; interquartile range: 5.3-15.8). Hypertension incidence was compared by donor status using conditional logistic regression, with BMI change investigated for effect modification.

RESULTS

Overall, LKDs and nondonors had similar hypertension incidence [incidence rate ratio (IRR): 1.16, 95% confidence interval (95% CI): 0.94-1.43, P =0.16], even after adjusting for BMI change (IRR: 1.25, 95% CI: 0.99-1.58, P =0.05). Although LKDs and nondonors who lost >5% BMI had comparable hypertension incidence (IRR: 0.78, 95% CI: 0.46-1.34, P =0.36), there was a significant interaction between donor and >5% BMI gain (multiplicative interaction IRR: 1.62, 95% CI: 1.15-2.29, P =0.006; relative excess risk due to interaction: 0.90, 95% CI: 0.24-1.56, P =0.007), such that LKDs who gained weight had higher hypertension incidence than similar nondonors (IRR: 1.83, 95% CI: 1.32-2.53, P <0.001).

CONCLUSIONS

Overall, LKDs and nondonors with obesity had similar hypertension incidence. Weight stability and loss were associated with similar hypertension incidence by donor status. However, LKDs who gained >5% saw increased hypertension incidence versus similar nondonors, providing support for counseling potential LKDs with obesity on weight management postdonation.

Diabetes-free survival among living kidney donors and non-donors with obesity: A longitudinal cohort study

BACKGROUND

Approval of living kidney donors (LKD) with end-stage kidney disease (ESKD) risk factors, such as obesity, has increased. While lifetime ESKD development data are lacking, the study of intermediate outcomes such as diabetes is critical for LKD safety. Donation-attributable diabetes risk among persons with obesity remains unknown. The purpose of this study was to evaluate 10-year diabetes-free survival among LKDs and non-donors with obesity.

METHODS

This longitudinal cohort study identified adult, LKDs (1976-2020) from 42 US transplant centers and non-donors from the Coronary Artery Risk Development in Young Adults (1985-1986) and the Atherosclerosis Risk in Communities (1987-1989) studies with body mass index ≥30 kg/m2. LKDs were matched to non-donors on baseline characteristics (age, sex, race, body mass index, systolic and diastolic blood pressure) plus diabetes-specific risk factors (family history of diabetes, impaired fasting glucose, smoking history). Accelerated failure time models were utilized to evaluate 10-year diabetes-free survival.

FINDINGS

Among 3464 participants, 1119 (32%) were LKDs and 2345 (68%) were non-donors. After matching on baseline characteristics plus diabetes-specific risk factors, 4% (7/165) LKDs and 9% (15/165) non-donors developed diabetes (median follow-up time 8.5 (IQR: 5.6-10.0) and 9.1 (IQR: 5.9-10.0) years, respectively). While not significant, LKDs were estimated to live diabetes-free 2 times longer than non-donors (estimate 1.91; 95% CI: 0.79-4.64, p = 0.15).

CONCLUSIONS

LKDs with obesity trended toward living longer diabetes-free than non-donors with obesity, suggesting within the decade following donation there was no increased diabetes risk among LKDs. Further work is needed to evaluate donation-attributable diabetes risk long-term.

Ten things every neurologist needs to know about neuropsychological assessments and interventions in people with epilepsy

This paper describes 10 core features of a neuropsychological assessment with the aim of helping neurologists understand the unique contribution the evaluation can make within the wider context of diagnostic methods in epilepsy. The possibilities, limitations and cautions associated with the investigation are discussed under the following headings. (1) A neuropsychological assessment is a collaborative investigation. (2) Assessment prior to treatment allows for the accurate assessment of treatment effects. (3) The nature of an underlying lesion and its neurodevelopmental context play an important role in shaping the associated neuropsychological deficit. (4) Cognitive and behavioural impairments result from the essential comorbidities of epilepsy which can be considered as much a disorder of cognition and behaviour as of seizures. (5) Patients' subjective complaints can help us understand objective cognitive impairments and their underlying neuroanatomy, resulting in improved patient care. At other times, patient complaints reflect other factors and require careful interpretation. (6) The results from a neuropsychological assessment can be used to maximize the educational and occupational potentials of people with epilepsy. (7) Not all patients are able to engage with a neuropsychological assessment. (8) There are limitations in assessments conducted in a second language with tests that have been standardized on different populations from that of the patient. (9) Adequate intervals between assessments maximize sensitivity to meaningful change. (10) Patients should be fully informed about the purpose of the assessment and have realistic expectations of the outcome prior to referral.

Glycerol Hydrogen-Bonding Network Dominates Structure and Collective Dynamics in a Deep Eutectic Solvent

The deep eutectic solvent glyceline formed by choline chloride and glycerol in 1:2 molar ratio is much less viscous compared to glycerol, which facilitates its use in many applications where high viscosity is undesirable. Despite the large difference in viscosity, we have found that the structural network of glyceline is completely defined by its glycerol constituent, which exhibits complex microscopic dynamic behavior, as expected from a highly correlated hydrogen-bonding network. Choline ions occupy interstitial voids in the glycerol network and show little structural or dynamic correlations with glycerol molecules. Despite the known higher long-range diffusivity of the smaller glycerol species in glyceline, in applications where localized dynamics is essential (e.g., in microporous media), the local transport and dynamic properties must be dominated by the relatively loosely bound choline ions.

Sensitivity of the UK Clinical Practice Research Datalink to Detect Neurodevelopmental Effects of Medicine Exposure in Utero: Comparative Analysis of an Antiepileptic Drug-Exposed Cohort

Introduction

Electronic healthcare data have several advantages over prospective observational studies, but the sensitivity of data on neurodevelopmental outcomes and its comparability with data generated through other methodologies is unknown.

Objectives

The objectives of this study were to determine whether data from the UK Clinical Practice Research Datalink (CPRD) produces similar risk estimates to a prospective cohort study in relation to the risk of neurodevelopmental disorders (NDDs) following prenatal antiepileptic drug (AED) exposure.

Methods

A cohort of mother–child pairs of women with epilepsy (WWE) was identified in the CPRD and matched to a cohort without epilepsy. The study period ran from 1 January 2000 to 31 March 2007 and children were required to be in the CPRD at age 6 years. AED exposure during pregnancy was determined from prescription data and children with an NDD diagnosis by 6 years were identified from Read clinical codes. The prevalence and risk of NDDs was calculated for mother–child pairs in WWE stratified by AED regimen and for those without epilepsy. Comparisons were made with the results of the prospective Liverpool and Manchester Neurodevelopment Group study which completed assessment on 201 WWE and 214 without epilepsy at age 6 years.

Results

In the CPRD, 1018 mother–child pairs to WWE and 6048 to women without epilepsy were identified. The CPRD identified a lower prevalence of NDDs than the prospective study. In both studies, NDDs were more frequently reported in children of WWE than women without epilepsy, although the CPRD risk estimate was lower (2.16 vs. 0.96%, p < 0.001 and 7.46 vs. 1.87%, p = 0.0128). NDD prevalence differed across AED regimens but the CPRD data did not replicate the significantly higher risk of NDDs following in utero monotherapy valproate exposure (adjusted odds ratio [OR_adj] 2.02, 95% confidence interval [CI] 0.52–7.86) observed in the prospective study (OR_adj 6.05, 95% CI 1.65–24.53).

Conclusion

It was possible to identify NDDs in the CPRD; however, the CPRD appears to under-record these outcomes. Larger studies are required to investigate further.

Electronic supplementary material

The online version of this article (doi:10.1007/s40264-017-0506-5) contains supplementary material, which is available to authorized users.

The relevance of neuropsychiatric symptoms and cognitive problems in new-onset epilepsy - Current knowledge and understanding

Neurobehavioral and cognition problems are highly prevalent in epilepsy, but most research studies to date have not adequately addressed the precise nature of the relationship between these comorbidities and seizures. To address this complex issue and to facilitate collaborative, innovative research in the rising field of neurobehavioral comorbidities and cognition disturbances in new-onset epilepsy, international epilepsy experts met at the 3rd Halifax International Epilepsy Conference & Retreat at White Point, South Shore, Nova Scotia, Canada from September 18 to 20, 2014. This Conference Proceedings provides a summary of the conference proceedings. Specifically, the following topics are discussed: (i) role of comorbidities in epilepsy diagnosis and management, (ii) role of antiepileptic medications in understanding the relationship between epilepsy and neurobehavioral and cognition problems, and (iii) animal data and diagnostic approaches. Evidence to date, though limited, strongly suggests a bidirectional relationship between epilepsy and cognitive and psychiatric comorbidities. In fact, it is likely that seizures and neurobehavioral problems represent different symptoms of a common etiology or network-wide disturbance. As a reflection of this shared network, psychiatric comorbidities and/or cognition problems may actually precede the seizure occurrence and likely get often missed if not screened.

Disentangling the relationship between epilepsy and its behavioral comorbidities - the need for prospective studies in new-onset epilepsies

It has been long recognized that there is more to epilepsy than seizures. The prevalence of such neurobehavioral abnormalities as cognitive and mood disorders, autism spectrum disorder, and attention deficit and hyperactivity disorder (ADHD) is significantly higher among patients with epilepsy than in the general population. A long-held view that comorbidities of epilepsy represent mere epiphenomena of seizures has undergone substantial transformation during the past decade, as emerging clinical evidence and experimental evidence suggest the involvement of specific neurobiological mechanisms in the evolution of neurobehavioral deficits in patients with epilepsy. Developmental aspects of both epilepsy and its comorbidities, as well as the frequently reported reciprocal connection between these disorders, both add other dimensions to the already complex problem. In light of progress in effective seizure management in many patients with epilepsy, the importance of neurobehavioral comorbidities has become acute, as the latter are frequently more detrimental to patients' quality of life compared with seizures. This calls for a serious increase in efforts to effectively predict, manage, and ideally cure these comorbidities. Coordinated multicenter clinical, translational, and basic research studies focusing on epidemiology, neuropsychology, neurophysiology, imaging, genetics, epigenetics, and pharmacology of neurobehavioral comorbidities of epilepsy are absolutely instrumental for ensuring tangible progress in the field. Clinical research should focus more on new-onset epilepsy and put particular emphasis on longitudinal studies in large cohorts of patients and groups at risk, while translational research should primarily focus on the development of valid preclinical systems which would allow investigating the fundamental mechanism of epilepsy comorbidities. The final goal of the described research efforts would lie in producing an armamentarium of evidence-based diagnostic tools and therapeutic interventions which would at minimum mitigate and at maximum prevent or abolish neurobehavioral comorbidities of epilepsy and, thus, improve the quality of life of those patients with epilepsy who suffer from the said comorbidities.

Effects of fetal antiepileptic drug exposure: outcomes at age 4.5 years

OBJECTIVE

To examine outcomes at age 4.5 years and compare to earlier ages in children with fetal antiepileptic drug (AED) exposure.

METHODS

The NEAD Study is an ongoing prospective observational multicenter study, which enrolled pregnant women with epilepsy on AED monotherapy (1999-2004) to determine if differential long-term neurodevelopmental effects exist across 4 commonly used AEDs (carbamazepine, lamotrigine, phenytoin, or valproate). The primary outcome is IQ at 6 years of age. Planned analyses were conducted using Bayley Scales of Infant Development (BSID at age 2) and Differential Ability Scale (IQ at ages 3 and 4.5).

RESULTS

Multivariate intent-to-treat (n = 310) and completer (n = 209) analyses of age 4.5 IQ revealed significant effects for AED group. IQ for children exposed to valproate was lower than each other AED. Adjusted means (95% confidence intervals) were carbamazepine 106 (102-109), lamotrigine 106 (102-109), phenytoin 105 (102-109), valproate 96 (91-100). IQ was negatively associated with valproate dose, but not other AEDs. Maternal IQ correlated with child IQ for children exposed to the other AEDs, but not valproate. Age 4.5 IQ correlated with age 2 BSID and age 3 IQ. Frequency of marked intellectual impairment diminished with age except for valproate (10% with IQ <70 at 4.5 years). Verbal abilities were impaired for all 4 AED groups compared to nonverbal skills.

CONCLUSIONS

Adverse cognitive effects of fetal valproate exposure persist to 4.5 years and are related to performances at earlier ages. Verbal abilities may be impaired by commonly used AEDs. Additional research is needed.

Child development following in utero exposure: levetiracetam vs sodium valproate

OBJECTIVE

Children born to women with epilepsy (WWE), exposed in utero to levetiracetam (LEV, n = 51), were assessed for early cognitive development and compared to children exposed to sodium valproate in utero (VPA, n = 44) and a group of children representative of the general population (n = 97).

METHODS

Children were recruited prospectively from 2 cohorts in the United Kingdom and assessed using the Griffiths Mental Development Scale (1996), aged <24 months. Information regarding maternal demographics were collected and controlled for. This is an observational study with researchers not involved in the clinical management of the WWE.

RESULTS

On overall developmental ability, children exposed to LEV obtained higher developmental scores when compared to children exposed to VPA (p < 0.001). When compared, children exposed to LEV did not differ from control children (p = 0.62) on overall development. Eight percent of children exposed to LEV in utero fell within the below average range (DQ score of <84), compared with 40% of children exposed to VPA. After controlling for maternal epilepsy and demographic factors using linear regression analysis, exposure to LEV in utero was not associated with outcome (p = 0.67). Conversely, when compared with VPA exposure, LEV exposure was associated with higher scores for the overall developmental quotient (p < 0.001).

CONCLUSION

Children exposed to LEV in utero are not at an increased risk of delayed early cognitive development under the age of 24 months. LEV may therefore be a preferable drug choice, where appropriate, for WWE prior to and of childbearing age.

Adverse antiepileptic drug effects in new-onset seizures: a case-control study

OBJECTIVE

Adverse effects (AEs) are a major concern when starting antiepileptic drug (AED) treatment. This study quantified the extent to which AE reporting in people with new-onset seizures started on AEDs is attributable to the medication per se, and investigated variables contributing to AE reporting.

METHODS

We pooled data from 2 large prospective studies, the Multicenter Study of Early Epilepsy and Single Seizures and the Northern Manhattan Study of incident unprovoked seizures, and compared adverse event profile (AEP) total and factor scores between adult cases prescribed AEDs for new-onset seizures and untreated controls, adjusting for several demographic and clinical variables. Differences in AEP scores were also tested across different AED monotherapies and controls, and between cases and controls grouped by number of seizures.

RESULTS

A total of 212 cases and 206 controls were identified. Most cases (94.2%) were taking low AED doses. AEP scores did not differ significantly between the 2 groups. Depression, female gender, symptomatic etiology, younger seizure onset age, ≥2 seizures, and history of febrile seizures were associated with higher AEP scores. There were no significant differences in AEP scores across different monotherapies and controls. AEP scores increased in both cases and controls with increasing number of seizures, the increment being more pronounced in cases.

CONCLUSIONS

When AED treatment is started at low doses following new-onset seizures, AE reporting does not differ from untreated individuals. Targeting specific factors affecting AE reporting could lead to improved tolerability of epilepsy treatment.

The detection of malingering in memory performance: The sensitivity and specificity of four measures in a UK population

OBJECTIVES

To investigate the validity of a clinical neuropsychological battery for the detection of malingering on tests of memory.

METHODS

A simulated scenario design was developed to investigate the effectiveness of a battery of four neuropsychological tests in the detection of malingering; the Coin in the Hand Test (CIH), Autobiographical Memory Index (AMI), Rey I 5-Item Test (RIT),and the Wechsler Mental Control Test (MCT). The performances of patients with an acquired brain injury (N = 40) were compared with two groups of controls instructed either to simulate a head injury performance (N = 40) or do their best (N = 40).

RESULTS

The CIH and MCT demonstrated good validity and displayed high sensitivity and specificity. The RIT and the AMI was relatively poor in distinguishing between simulators and patients.

CONCLUSIONS

The sensitivity and specificity of all four tests to the detection of malingering has been assessed. Two of the tests the CIH and MCT would be useful as a quick and accurate screening tool for detecting malingering.

Effects of breastfeeding in children of women taking antiepileptic drugs

BACKGROUND

Breastfeeding is known to have beneficial effects, but there is concern that breastfeeding during antiepileptic drug (AED) therapy may be harmful to cognitive development. Animal and human studies have demonstrated that some AEDs can adversely affect the immature brain. However, no investigation has examined effects of breastfeeding during AED therapy on subsequent cognitive abilities in children.

METHODS

The Neurodevelopmental Effects of Antiepileptic Drugs Study is an ongoing prospective multicenter observational investigation of long-term effects of in utero AED exposure on cognition. Between 1999 and 2004, we enrolled pregnant women with epilepsy who were taking a single AED (carbamazepine, lamotrigine, phenytoin, or valproate). We recently reported on differential AED effects on age 3 year cognitive outcomes. In this report, we focus on the effects of breastfeeding during AED therapy on age 3 cognitive outcomes in 199 children.

RESULTS

A total of 42% of children were breastfed. IQs for breastfed children did not differ from nonbreastfed children for all AEDs combined and for each of the 4 individual AED groups. Mean adjusted IQ scores (95% confidence intervals) across all AEDs were breastfed = 99 (96-103) and nonbreastfed = 98 (95-101). Power was 95% to detect a half SD IQ effect in the combined AED analysis, but was inadequate within groups.

CONCLUSIONS

This preliminary analysis fails to demonstrate deleterious effects of breastfeeding during AED therapy on cognitive outcomes in children previously exposed in utero. However, caution is advised due to study limitations. Additional research is needed to confirm this observation and extend investigations to other AEDs and polytherapy.

Pregnancy with epilepsy: obstetric and neonatal outcome of a controlled study

PURPOSE

To determine the influence of epilepsy and its treatment on pregnancy and its outcome.

DESIGN

Controlled, observational study.

SETTING

National Health Service maternity hospitals in Liverpool and Manchester regions.

POPULATION

277 women with epilepsy (WWE) and 315 control women.

METHODS

WWE were recruited from antenatal clinics. Controls were matched for age and parity but not gestational age. Information was obtained by interview and from clinical records.

MAIN OUTCOME MEASURES

Obstetric complications, mode of delivery, condition of newborn.

RESULTS

Distribution of epilepsy syndromes was similar to previous surveys. Most WWE (67%) received monotherapy with carbamazepine, sodium valproate or lamotrigine. Half WWE had no seizures during pregnancy but 34% had tonic clonic seizures. Seizure-related injuries were infrequent. Pregnancies with obstetric complications were increased in women with treated epilepsy (WWTE 45%, controls 33%; p=0.01). Most had normal vaginal delivery (WWTE 63%, controls 61%; p=0.65). Low birth weight was not increased (WWTE 6.2%, controls 5.2%; p=0.69). There were more major congenital malformations (MCM) (WWTE 6.6%, controls 2.1%; p=0.02) and fetal/infant deaths (WWTE 2.2%, controls 0.3%; p=0.09). Amongst monotherapies MCM prevalence was highest with valproate (11.3%; p=0.005). Lamotrigine (5.4%; p=0.23) and carbamazepine (3.0%; p=0.65) were closer to controls (2.1%). There was no association between MCM and dose of folic acid pre-conception.

CONCLUSION

MCM were more prevalent in the babies of WWTE particularly amongst those receiving sodium valproate.

Psychogenic non-epileptic seizures--definition, etiology, treatment and prognostic issues: a critical review

In this review we systematically assess our currently available knowledge about psychogenic non-epileptic seizures (PNES) with an emphasis on the psychological mechanisms that underlie PNES, possibilities for psychological treatment as well as prognosis. Relevant studies were identified by searching the electronic databases. Case reports were not considered. 93 papers were identified; 65 of which were studies. An open non-randomized design, comparing patients with PNES to patients with epilepsy is the dominant design. A working definition for PNES is proposed. With respect to psychological etiology, a heterogeneous set of factors have been identified. Not all factors have a similar impact, though. On the basis of this review we propose a model with several factors that may interact in both the development and prolongation of PNES. These factors involve psychological etiology, vulnerability, shaping, as well as triggering and prolongation factors. A necessary first step of intervention in patients with PNES seems to be explaining the diagnosis with care. Although the evidence for the efficacy of additional treatment strategies is limited, variants of cognitive (behavioural) therapy showed to be the preferred type of treatment for most patients. The exact choice of treatment should be based on individual differences in the underlying factors. Outcome can be measured in terms of seizure occurrence (frequency, severity), but other measures might be of greater importance for the patient. Prognosis is unclear but studies consistently report that 1/3rd to 1/4th of the patients become chronic.

Knowledge gaps and uncertainties about epilepsy: findings from an ethnographic study in China

Epilepsy represents one of the major brain disorders worldwide. In China, research into how much people with epilepsy know about their condition appears limited. Drawing on data collected as part of a large ethnographic study, we present the experiences and views of Chinese people with epilepsy and their family members, to identify knowledge gaps and uncertainties about epilepsy within selected urban and rural communities. We also examine how respondents' demographic characteristics influence their knowledge, understanding, and beliefs about epilepsy. We found knowledge and understanding of epilepsy to be uneven and context specific. Hereditary factors were most frequently cited as a potential cause, although their impact remained unclear. Western medicalization of epilepsy appears less evident in the reports of rural informants, where traditional beliefs continue to shape definitions and treatment. Societal differences within these communities set boundaries on knowledge acquisition. Plotted against these differences, we suggest strategies for proposed educational/psychosocial intervention programs.

The behavioral consequences of exposure to antiepileptic drugs in utero

The aim of the study was to examine the behavior of 242 children, aged between 6 and 16 years, born to mothers with epilepsy. Exposure to sodium valproate (VPA) in utero was associated with high levels of parental stress induced by the child's maladaptive behavior. These children were also poorer for daily living skills and skills relating to socialization. The outcomes on both measures were strongly affected by the Full Scale IQ (FSIQ) of the child; however, no significant differences were found between the groups and therefore this pattern of results cannot simply be attributed to a lower FSIQ. The results of this study suggest that exposure to VPA in utero and the presence of a lowered FSIQ are risk factors for the development of poorer adaptive behavior and a higher rate of maladaptive behaviors.

A randomised controlled trial examining the longer-term outcomes of standard versus new antiepileptic drugs. The SANAD trial

OBJECTIVES

To compare clinicians' choice of one of the standard epilepsy drug treatments (carbamazepine or valproate) versus appropriate comparator new drugs.

DESIGN

A clinical trial comprising two arms, one comparing new drugs in carbamazepine and the other with valproate.

SETTING

A multicentre study recruiting patients with epilepsy from hospital outpatient clinics.

PARTICIPANTS

Patients with an adequately documented history of two or more clinically definite unprovoked epileptic seizures within the last year for whom treatment with a single antiepileptic drug represented the best therapeutic option.

INTERVENTIONS

Arm A was carbamazepine (CBZ) versus gabapentin (GBP) versus lamotrigine (LTG) versus oxcarbazepine (OXC) versus topiramate (TPM). Arm B valproate (VPS) versus LTG versus TPM.

MAIN OUTCOME MEASURES

Time to treatment failure (withdrawal of the randomised drug for reasons of unacceptable adverse events or inadequate seizure control or a combination of the two) and time to achieve a 12-month remission of seizures. Time from randomisation to first seizure, 24-month remission of seizures, incidence of clinically important adverse events, quality of life (QoL) outcomes and health economic outcomes were also considered.

RESULTS

Arm A recruited 1721 patients (88% with symptomatic or cryptogenic partial epilepsy and 10% with unclassified epilepsy). Arm B recruited 716 patients (63% with idiopathic generalised epilepsy and 25% with unclassified epilepsy). In Arm A LTG had the lowest incidence of treatment failure and was statistically superior to all drugs for this outcome with the exception of OXC. Some 12% and 8% fewer patients experienced treatment failure on LTG than CBZ, the standard drug, at 1 and 2 years after randomisation, respectively. The superiority of LTG over CBZ was due to its better tolerability but there is satisfactory evidence indicating that LTG is not clinically inferior to CBZ for measures of its efficacy. No consistent differences in QoL outcomes were found between treatment groups. Health economic analysis supported LTG being preferred to CBZ for both cost per seizure avoided and cost per quality-adjusted life-year gained. In Arm B for time to treatment failure, VPS, the standard drug, was preferred to both TPM and LTG, as it was the drug least likely to be associated with treatment failure for inadequate seizure control and was the preferred drug for time to achieving a 12-month remission. QoL assessments did not show any between-treatment differences. The health economic assessment supported the conclusion that VPS should remain the drug of first choice for idiopathic generalised or unclassified epilepsy, although there is a suggestion that TPM is a cost-effective alternative to VPS.

CONCLUSIONS

The evidence suggests that LTG may be a clinical and cost-effective alternative to the existing standard drug treatment, CBZ, for patients diagnosed as having partial seizures. For patients with idiopathic generalised epilepsy or difficult to classify epilepsy, VPS remains the clinically most effective drug, although TPM may be a cost-effective alternative for some patients. Three new antiepileptic drugs have recently been licensed in the UK for the treatment of epilepsy (levetiracetam, zonisamide and pregabalin), therefore these drugs should be compared in a similarly designed trial.

Knowledge of and attitudes expressed toward epilepsy by carers of people with epilepsy: a UK perspective

OBJECTIVE

The aim of this study was to investigate the knowledge and attitudes possessed by carers of people with epilepsy.

METHODS

A postal survey of 2000 carers recruited from the membership list of a UK epilepsy charity was conducted using a standard set of questions. The questions covered their knowledge of epilepsy (e.g., estimating prevalence and identifying causes of epilepsy) and their attitudes (e.g., about the characteristics of people with epilepsy).

RESULTS

Overall, 651 carers responded. Only 29% of carers were male, with the majority between 40 and 60 years of age. The majority of respondents (76%) overestimated the prevalence of epilepsy. Twenty-five percent believed that epilepsy was caused by stress. The majority of respondents believed that people with epilepsy were treated differently by others. Only a small percentage believed that people with epilepsy should be barred from such professions as teaching and nursing.

CONCLUSIONS

Carers of people with epilepsy generally possessed high levels of knowledge about most aspects of epilepsy, and their attitudes toward those with epilepsy were benign. There were, however, particular groups who were more likely to hold more positive attitudes, and these included younger and better-educated individuals. Limitations of this study include that the sample was self-selected and that only a third of the people to whom the questionnaire was mailed responded.

Self-management education for adults with epilepsy

BACKGROUND

Self-management education has been shown to improve the quality of life of people with chronic illnesses. It has been suggested that self-management education may improve seizure control and other outcomes in people with epilepsy.

OBJECTIVES

To review systematically the research literature on the effectiveness of self-management education in improving health outcomes for adults with epilepsy.

SEARCH STRATEGY

We searched MEDLINE (Ovid) (1966 to April 2005), EMBASE (Ovid) (1980 to April 2005), CINAHL (Dialog) (1980 to April 2005), PsycINFO (Dialog) (1887 to April 2005), and the Cochrane Epilepsy Group's Specialised Register (April 2005). We also handsearched Epilepsia and conference abstracts and proceedings. Experts in the field were contacted to identify any additional trials. We did not impose any language restriction. We re-ran the searches in February 2007 and added the identified references to the 'Studies awaiting assessment' table.

SELECTION CRITERIA

Randomised trials of self-management education programmes for adults with epilepsy.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the quality of each study and extracted data.

MAIN RESULTS

Two trials evaluated the effect of self-management education for adults with epilepsy, neither of which assessed as being of high quality. In total, 483 adults with epilepsy were randomised. Both trials showed improvements in seizure frequency and other outcomes, such as knowledge. However, we were not able to estimate a summary effect for seizure frequency due to a lack of data.

AUTHORS' CONCLUSIONS

Self-management education programmes, based on increasing understanding through psychosocial methods, may improve knowledge about epilepsy, certain behavioural outcomes, and reduce seizure frequency. It is, however, not clear how effective self-management programmes of epilepsy would be in a more general population of adults with epilepsy, as both trials had higher proportions of people with partial seizures than would be expected in a community sample.

Self-management education for children with epilepsy

BACKGROUND

Self-management education has been shown to improve the quality of life of children and young people with chronic illnesses. It has been suggested that self-management education may improve seizure control and other outcomes in children and young people with epilepsy.

OBJECTIVES

To review systematically the research literature on the effectiveness of self-management education in improving health outcomes for children and young people with epilepsy.

SEARCH STRATEGY

We searched the Cochrane Epilepsy Group's Specialised Register (April 2007), MEDLINE (Ovid) (1966 to February 2007), EMBASE (Ovid) (1980 to February 2007), CINAHL (Dialog) (1980 to February 2007), and PsycINFO (Dialog) (1887 to February 2007). We also handsearched Epilepsia and conference abstracts and proceedings. Experts in the field were contacted to identify any additional trials. No language restriction was imposed.

SELECTION CRITERIA

Randomised trials of self-management education programmes for children or young people with epilepsy.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the quality of each study and extracted data.

MAIN RESULTS

Only one trial involving 167 children was identified that evaluated the effect of a child-centred model of training for the self-management of two chronic illnesses, asthma and epilepsy. The trial was not assessed as being of high quality and the methods used to analyse and report the data did not enable us to precisely determine the effect of the intervention. However, improvements were seen in seizure frequency and other outcomes, such as knowledge and behaviour.

AUTHORS' CONCLUSIONS

Self-management education programmes that deliver a child-centred model of training, may improve knowledge about epilepsy, certain behavioural outcomes, and reduce seizure frequency in children and young people with epilepsy. However, based on the evidence reviewed, we are not able to determine how effective it is, or what the key components of the programme should be.

Treatments for non-epileptic attack disorder

BACKGROUND

Psychogenic non-epileptic seizures (NES) have the outward appearance of epilepsy in the absence of physiological or electroencephalographic correlates. Non-epileptic seizures can occur in isolation or in combination with epileptic seizures. The development and maintenance of non-epileptic seizures has been well documented and there is a growing literature on the treatment of NES which includes non-psychological (including anti-anxiety and antidepressant pharmacological treatment) and psychological therapies (including cognitive behavioural therapy (CBT), hypnotherapy and paradoxical therapy). Various treatment methodologies have been tried with variable success. The purpose of this Cochrane review was to establish the evidence base for the treatment of NES.

OBJECTIVES

To assess whether treatments for NES result in a reduction in frequency of seizures and/or improvement in quality of life, and whether any treatment is significantly more effective than others.

SEARCH STRATEGY

We searched the Cochrane Epilepsy Group's Specialised Register (September 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to July 2005), and PsycINFO (1806 to July 2005). No language restrictions were imposed. We checked the reference lists of retrieved studies for additional reports of relevant studies

SELECTION CRITERIA

Randomised or quasi-randomised studies were included that assessed one or more types of psychological or non-psychological interventions for the treatment of NES. Studies of childhood NES were excluded from our review.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the trials for inclusion and extracted data. Outcomes included reduction in seizure frequency and improvements in quality of life.

MAIN RESULTS

Three small studies met our inclusion criteria and were of poor methodological quality. Two assessed hypnosis and the other paradoxical therapy. There were no detailed reports of improved seizure frequency or quality of life outcomes, and these trials provide no reliable evidence of a beneficial effect of these interventions.

AUTHORS' CONCLUSIONS

In view of the methodological limitations and the small number of studies, we have no reliable evidence to support the use of any treatment including hypnosis or paradoxical injunction therapy in the treatment of NES. Randomised studies of these and other interventions are needed.

Interaction of influenza virus fusion peptide with lipid membranes: effect of lysolipid

The effect of lysophosphatidylcholine (LPC) on lipid vesicle fusion and leakage induced by influenza virus fusion peptides and the peptide interaction with lipid membranes were studied by using fluorescence spectroscopy and monolayer surface tension measurements. It was confirmed that the wild-type fusion peptide-induced vesicle fusion rate increased several-fold between pH 7 and 5, unlike a mutated peptide, in which valine residues were substituted for glutamic acid residues at positions 11 and 15. This mutated peptide exhibited a much greater ability to induce lipid vesicle fusion and leakage but in a less pH-dependent manner compared to the wild-type fusion peptide. The peptide-induced vesicle fusion and leakage were well correlated with the degree of interaction of these peptides with lipid membranes, as deduced from the rotational correlation time obtained for the peptide tryptophan fluorescence. Both vesicle fusion and leakage induced by the peptides were suppressed by LPC incorporated into lipid vesicle membranes in a concentration-dependent manner. The rotational correlation time associated with the peptide's tryptophan residue, which interacts with lipid membranes containing up to 25 mole % LPC, was virtually the same compared to lipid membranes without LPC, indicating that LPC-incorporated membrane did not affect the peptide interaction with the membrane. The adsorption of peptide onto a lipid monolayer also showed that the presence of LPC did not affect peptide adsorption.

A randomized controlled trial of a health promotion education programme for people with multiple sclerosis

Objective: To evaluate the effectiveness of a health promotion education programme for people with multiple sclerosis (the OPTIMISE programme) in terms of increasing the level of health-promoting activity undertaken, improving self-efficacy and enhancing quality of life.

Design: A randomized controlled single blinded trial. Non-parametric analysis was undertaken to test for significant differences between treatment and control groups change scores.

Subjects and setting: Sixty-two adults (32 treatment and 30 control subjects) with multiple sclerosis of any type, Expanded Disability Status Scale (EDSS) 1-7.

Intervention: An eight-week multidisciplinary outpatient health promotion education programme aimed at increasing knowledge, skills and confidence in undertaking health promotion activities.

Outcome measures: Health Promoting Lifestyle Profile, Self-Rated Abilities for Health Practices Scale and the Short Form 36 Item Health Survey.

Results: Following completion of the programme, treatment subjects had significantly higher levels of health promotion activity undertaken ( P<0.01) and self-efficacy for health promotion activities ( P<0.01). These benefits were sustained for at least three months after the programme ceased. Certain domains of quality of life also improved in treatment subjects more than controls (physical P=0.03, mental health and general health P=0.01), although only mental health and general health showed further improvement at three months. Participants provided positive feedback regarding the usefulness of the intervention and demonstrated observable changes to their health promotion behaviours.

Conclusions: The OPTIMISE programme produced significant changes in health-promoting behaviours.

In utero antiepileptic drug exposure: fetal death and malformations

BACKGROUND

Pregnancy outcomes following in utero exposure to antiepileptic drugs (AEDs) are uncertain, limiting an evidenced-based approach.

OBJECTIVE

To determine if fetal outcomes vary as a function of different in utero AED exposures.

METHODS

This ongoing prospective observational study across 25 epilepsy centers in the USA and UK enrolled pregnant women with epilepsy from October 1999 to February 2004 to determine if differential long-term cognitive and behavioral neurodevelopmental effects exist across the four most commonly used AEDs. This initial report focuses on the incidence of serious adverse outcomes including major congenital malformations (which could be attributable to AEDs) or fetal death. A total of 333 mother/child pairs were analyzed for monotherapy exposures: carbamazepine (n = 110), lamotrigine (n = 98), phenytoin (n = 56), and valproate (n = 69).

RESULTS

Response frequencies of pregnancies resulting in serious adverse outcomes for each AED were as follows: carbamazepine 8.2%, lamotrigine 1.0%, phenytoin 10.7%, and valproate 20.3%. Distribution of serious adverse outcomes differed significantly across AEDs and was not explained by factors other than in utero AED exposure. Valproate exhibited a dose-dependent effect.

CONCLUSIONS

More adverse outcomes were observed in pregnancies with in utero valproate exposure vs the other antiepileptic drugs (AEDs). These results combined with several recent studies provide strong evidence that valproate poses the highest risk to the fetus. For women who fail other AEDs and require valproate, the dose should be limited if possible.

Neuropsychological effects of exposure to anticonvulsant medication in utero

OBJECTIVE

To investigate the long-term differential drug effects on cognitive functioning in school-aged children exposed to antiepileptic drugs (AEDs) in utero.

METHODS

Mothers with epilepsy were recruited from specialist epilepsy clinics and obstetric clinics from the Liverpool and Manchester region. The mothers and their children were recruited without prior knowledge of their AED treatment during pregnancy or the health of the offspring. A battery of neuropsychological tests was applied to each mother-child pair in order to obtain a neuropsychological profile for each child.

RESULTS

Neuropsychological investigation was performed on 249 children between the ages of 6 and 16. Children exposed to sodium valproate had a significantly lower verbal IQ when compared to children exposed to other antiepileptic drugs or not exposed at all. The same children were more likely to have an IQ below 69 and more likely to have memory impairment when compared to the other groups. The mothers' IQ, exposure to sodium valproate, and the number of tonic-clonic seizures during pregnancy were significant predictors of verbal IQ in this population.

CONCLUSIONS

This retrospective study highlights the potential harmful effects of sodium valproate exposure in utero on neuropsychological development.

Psychological treatments for epilepsy

BACKGROUND

Psychological interventions such as relaxation therapy, cognitive behaviour therapy, bio-feedback and educational interventions have been used alone or in combination in the treatment of epilepsy, to reduce the seizure frequency and improve the quality of life.

OBJECTIVES

To assess whether the treatment of epilepsy with psychological methods is effective in reducing seizure frequency and/or leads to a better quality of life.

SEARCH STRATEGY

We searched the Cochrane Epilepsy Group's Specialized Register (July 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), and MEDLINE (1966 to March 2005). No language restrictions were imposed. We checked the reference lists of retrieved studies for additional reports of relevant studies.

SELECTION CRITERIA

Randomized or quasi-randomized studies assessing one or more types of psychological or behaviour modification techniques for people with epilepsy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trials for inclusion and extracted data. Primary analyses were by intention to treat. Outcomes included reduction in seizure frequency and quality of life.

MAIN RESULTS

We found three small trials (50 participants) of relaxation therapy. They were of poor methodological quality and a meta-analysis was therefore not undertaken. No study found a significant effect of relaxation therapy on seizure frequency. One trial found cognitive behavioural therapy to be effective in reducing depression, among people with epilepsy with a depressed affect, whilst another did not. One trial of group cognitive therapy found no significant effect on seizure frequency. Two trials of combined relaxation and behaviour therapy and one of EEG bio-feedback and four of educational interventions did not provide sufficient information to assess their effect on seizure frequency. One small study of galvanic skin response biofeedback reported significant reduction in seizure frequency. Combined use of relaxation and behaviour modification was found beneficial for anxiety and adjustment in one study. In one study EEG bio-feedback was found to improve the cognitive and motor functions in individuals with greatest seizure reduction. Educational interventions were found to be beneficial in improving the knowledge and understanding of epilepsy, coping with epilepsy, compliance to medication and social competencies.

AUTHORS' CONCLUSIONS

In view of methodological deficiencies and limited number of individuals studied, we have found no reliable evidence to support the use of these treatments and further trials are needed.

Neuropsychological assessment of a group of UK patients with Cohen syndrome

Cohen syndrome is a rare autosomal recessive syndrome with a distinctive clinical phenotype that includes mental retardation and a characteristic sociable disposition. Variability in the level of learning disability and the behavioural phenotype is seen in the published literature. In a cohort of Finnish Cohen syndrome patients, severe mental retardation and non-maladaptive behaviour were described. Outside of Finland, autistic-spectrum behaviour has been reported in a few isolated Cohen syndrome patients but in a recent UK study was found to be highly prevalent. We report the results of neuropsychological studies in a group of 16 genetically heterogeneous patients, all with the characteristic clinical features of Cohen syndrome. Of the 9 patients who underwent formal neuropsychological testing, all but one was functioning in the severely mentally impaired range. Of the remaining patients, 3 were below the age of formal testing and 4 had such profound learning and behavioural problems that they were deemed unable to participate in testing. Mild maladaptive behaviour was observed in 13 patients and 3 were documented as having significant maladaptive behaviour. In contrast to the Finnish group of Cohen syndrome patients, this UK study identifies significant neuropsychological impairment combined with maladaptive behaviour as a characteristic of Cohen syndrome. Although autistic-type behaviour was observed, an increased prevalence of autism in Cohen syndrome was not confirmed.

Psychological treatments for epilepsy

BACKGROUND

Psychological interventions such as relaxation therapy, cognitive behaviour therapy, electroencephalogram (EEG) bio-feedback and educational interventions have been used alone or in combination in the treatment of epilepsy, to reduce the seizure frequency and improve the quality of life.

OBJECTIVES

To assess whether the treatment of epilepsy with psychological methods is effective in reducing seizure frequency and/or leads to a better quality of life.

SEARCH STRATEGY

We searched the Cochrane Epilepsy Group trial register (11 June 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 2, 2003), MEDLINE (on 11 June 2003) and cross references from identified publications.

SELECTION CRITERIA

Randomized or quasi-randomized studies assessing one or more types of psychological or behaviour modification techniques for people with epilepsy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the trials for inclusion and extracted data. Primary analyses were by intention to treat. Outcomes included reduction in seizure frequency and quality of life.

MAIN RESULTS

We found three small trials (50 participants) of relaxation therapy. They were of poor methodological quality and a meta-analysis was therefore not undertaken. No study found a significant effect of relaxation therapy on seizure frequency. One trial found cognitive behavioural therapy to be effective in reducing depression, among people with epilepsy with a depressed affect, whilst another did not. One trial of group cognitive therapy found no significant effect on seizure frequency. Two trials of combined relaxation and behaviour therapy and one of EEG bio-feedback and four of educational interventions did not provide sufficient information to assess their effect on seizure frequency. Combined use of relaxation and behaviour modification was found beneficial for anxiety and adjustment in one study. In one study EEG bio-feedback was found to improve the cognitive and motor functions in individuals with greatest seizure reduction. Educational interventions were found to be beneficial in improving the knowledge and understanding of epilepsy, coping with epilepsy, compliance to medication and social competencies.

REVIEWER'S CONCLUSIONS

In view of methodological deficiencies and limited number of individuals studied, we have found no reliable evidence to support the use of these treatments and further trials are needed.

The A-B neuropsychological assessment schedule (ABNAS): the relationship between patient-perceived drug related cognitive impairment and results of neuropsychological tests

Our intention was to evaluate the relationships between the A-B neuropsychological assessment schedule (ABNAS) as a measure of patient-perceived cognitive effects of antiepileptic drugs (AEDs) and the results of neuropsychological tests. The measure was developed specifically to assess patient-perceived cognitive effects of AED treatment. Evidence of its reliability and validity has been previously documented. In this study 96 patients were included using stratified inclusion-criteria to guarantee variability of performance: 55 patients were included from a 'low risk condition' with respect to possible cognitive effect (i.e. monotherapy carbamazepine within a dose range of 600-1200 mg/day) and 41 patients were included from a 'high risk condition' (i.e. polytherapy of three or two AEDs including either phenytoin, phenobarbitone or a benzodiazepine; treatment with topiramate with a titration speed using 50 mg or higher increments per week and within the first 6 months of treatment). All patients were prospectively assessed using the ABNAS and five neuropsychological tests (all part of the FePsy test system) with proven sensitivity of cognitive effects of antiepileptics: three tasks using reaction-time to measure speed ('simple (visual) reaction-time measurement', 'the binary choice reaction test' and 'the computerized visual searching task'); one test measuring motor speed ('the finger tapping task'); and a memory test ('recognition of words'). The three reaction-time tasks and the finger tapping test were significantly correlated with the ABNAS-score with correlations ranging from 0.22 to 0.35. The highest correlation was with 'simple (visual) reaction-time measurement' (0.35). Discriminant analysis showed that with the neuropsychological tests 61.5% of the patients were correctly identified as having high/low ABNAS-scores. The ABNAS underestimated impairment in 17.8% of the patients ( = low ABNAS-score but impairment on the neuropsychological tests). The present study contributes to the already existing evidence of validity of the ABNAS as a screening instrument for clinical practice as the relationship between the ABNAS-score and results of neuropsychological tests can help to identify who is at risk and needs further referral for neuropsychological assessment. Moreover the correlation between ABNAS-score and those neuropsychological tests that are sensitive for drug-effects may provide a sensitive instrument in early drug-development phases while keeping the burden on financial and time resources to a minimum.

Effects of fluorescent probe structure on the dynamics at cysteine-34 within bovine serum albumin: evidence for probe-dependent modulation of the cybotactic region

We have prepared a series of bovine serum albumins (BSA) that have been site-selectively labeled at cysteine-34 with one of four different sulfhydryl-selective boron dipyrromethene difluoride (BODIPY) fluorescent probes (BODIPY FL IA, BODIPY FL C(1) IA, BODIPY 530/550 IA, and BODIPY 493/503 MB). We determine how the choice of extrinsic probe structure dictates the recovered BSA-BODIPY dynamics under thermal (10-80 degrees C) and chemical (0-5M guanidine hydrochloride) denaturation conditions. The results of these experiments show that the global protein dynamics are sensed equally by each fluorescent probe; however, the probe itself influences the local probe dynamics within the cybotactic region that surrounds cysteine-34. Thus, it seems inappropriate to think of these extrinsic fluorescent probes as passive, nonparticipatory viewers of local protein dynamics.

Assessment of quality of life in people with epilepsy: some practical implications

Growing recognition of the need to assess the impact of epilepsy on psychosocial functioning has led to a number of initiatives to quantify quality of life (QOL) in patients with this condition. To understand the impact of epilepsy and its treatment, physical, social, neuropsychological, and psychological functioning aspects must be considered. It also is apparent from previous research work that measures of QOL should be comprehensive enough to address the question under consideration, but also simple and as brief as possible. A number of QOL measures for assessing the impact of epilepsy and its treatment exist, such as the Washington Psychosocial Seizure Inventory, the Social Effects Scale, the Epilepsy Surgery Inventory, the Quality of Life in Epilepsy (QOLIE) questionnaire, and the Liverpool QOL Battery. These measures have in most cases been shown to be reliable, valid, and sensitive to change, although at the current stage of development, some are better validated than others. It is generally agreed that the best approach is to use a standard generic instrument with disease-specific additions. Selection of a measure already in existence is recommended, as the process of producing a new measure is costly in terms of both resources and time. Some consideration also needs to be given to factors such as the process of administration (e.g., self-completion or administration at interview) or the timing of data collection. Then questions such as the cross-cultural applicability of QOL measures and the real relevance of the changes remain to be answered. It is hoped that, over the next few years, significant progress will be made in addressing these issues.

Measuring the impact of multiple sclerosis on psychosocial functioning: the development of a new self-efficacy scale

OBJECTIVE

To develop a scale to measure self-efficacy in neurologically impaired patients with multiple sclerosis and to assess the scale's psychometric properties.

DESIGN

Cross-sectional questionnaire study in a clinical setting, the retest questionnaire returned by mail after completion at home.

SETTING

Regional multiple sclerosis (MS) outpatient clinic or the Clinical Trials Unit (CTU) at a large neuroscience centre in the UK.

SUBJECTS

One hundred persons with MS attending the Walton Centre for Neurology and Neurosurgery and Clatterbridge Hospital, Wirral, as outpatients.

METHODS

Cognitively impaired patients were excluded at an initial clinic assessment. Patients were asked to provide demographic data and complete the self-efficacy scale along with the following validated scales: Hospital Anxiety and Depression Scale, Rosenberg Self-Esteem Scale, Impact, Stigma and Mastery and Rankin Scales. The Rankin Scale and Barthel Index were also assessed by the physician.

RESULTS

A new 11-item self-efficacy scale was constructed consisting of two domains of control and personal agency. The validity of the scale was confirmed using Cronbach's alpha analysis of internal consistency (alpha = 0.81). The test-retest reliability of the scale over two weeks was acceptable with an intraclass correlation coefficient of 0.79. Construct validity was investigated using Pearson's product moment correlation coefficient resulting in significant correlations with depression (r= -0.52) anxiety (r =-0.50) and mastery (r= 0.73). Multiple regression analysis demonstrated that these factors accounted for 70% of the variance of scores on the self-efficacy scale, with scores on mastery, anxiety and perceived disability being independently significant.

CONCLUSION

Assessment of the psychometric properties of this new self-efficacy scale suggest that it possesses good validity and reliability in patients with multiple sclerosis.

Cognitive and behavioural assessments in clinical trials: what type of measure?

This paper provides an overview of the types of neuropsychological and behavioural measures used in randomised controlled trials (RCTS) of antiepileptic drugs (AEDs) in patients with epilepsy. The results of previous systematic reviews are reported in respect of the methods used in clinical trials to assess cognitive and behavioural effects of AED treatment. There were 46 trials incorporating behavioural measures and 40 trials incorporating neuropsychological measures. The evidence supporting the choice of test, and their reliability, validity, and sensitivity to change was minimal. It is concluded that poor reporting of methods and a plethora of both neuropsychological and behavioural measures make it difficult to provide any meaningful comments about the effects of AED treatment. A much more standardised approach to assessing these effects is necessary.

Reliability, validity and responsiveness of a revised scoring system for the Liverpool Seizure Severity Scale

This report examines the reliability, validity and responsiveness of a revised scoring system for the Liverpool Seizure Severity Scale (LSSS). The revised scoring system was validated using archival data from an observational study and a randomized controlled study. Factor analyses confirmed that a single dimension captured how patients evaluate the severity of their most severe seizures occurring during a recall period. The revised scoring system repositions the severity score to range from 0 (no seizures) to 100 (most severe possible). Scores based on the new system were reliable, had construct validity (known-groups validity), and were responsive to changes in the patients' epilepsy as noted by their physicians. Results suggest that future epilepsy studies assessing seizure severity should incorporate the revised LSSS scoring system and a modified version of the questionnaire that simplifies self-assessment and analyses. The modified version of the LSSS and its scoring system are appended to this report.

The A-B neuropsychological assessment schedule (ABNAS): the further refinement of a patient-based scale of patient-perceived cognitive functioning

PURPOSE

To provide further evidence of the reliability and validity of the ABNAS as a measure of patient-perceived cognitive side effects of antiepileptic drug treatment.

METHODS

The measure was developed specifically to assess patient-perceived cognitive side effects of antiepileptic drug treatment. Evidence of its reliability and validity has been previously documented and this evidence has been further extended by administration of a battery of 400 questionnaires to two groups (200 people with epilepsy, PWE; and 200 controls who do not have epilepsy). The questionnaire packs consisted of the ABNAS, HADS, the everyday memory questionnaire, and the Adverse Events Profile. Data were analysed using MAP-R and SPSS.

RESULTS

Further evidence of the psychometric properties of the scale demonstrated that it had excellent reliability (Cronbach's alpha=0.96) and good face, congruent, content and construct validity. The sensitivity of the instrument was demonstrated through analysis of floor and ceiling levels.

CONCLUSIONS

The ABNAS is a reliable, tool for the detection of cognitive impairments associated with epilepsy and its treatment. We have provided further evidence of its criterion validity. This measure has the potential to be a useful tool for both clinical practice and clinical trials.

The quality of life of older people with epilepsy: findings from a UK community study

The impact of epilepsy on the quality of life of older people with epilepsy has rarely been investigated. As part of a large prevalence study of epilepsy conducted in one UK Health Region, we investigated the burden of their condition in older compared with younger people. A second analysis compared quality of life in those men and women diagnosed after the age of retirement from the workforce compared with those diagnosed before that age. Data were collected from men and women with epilepsy and from their primary and secondary care physicians. There were few differences between older and younger people with regard to their reported quality of life, though younger people were more likely to report feeling stigmatized by their condition. Older people with epilepsy diagnosed in later life were more anxious and depressed than those diagnosed earlier and their overall perception of quality of life was more likely to be negative. Our data emphasize that older people do not necessarily experience poorer quality of life than younger people, but those first diagnosed in later life do appear to have a quality of life which is more impaired. Consideration should be paid to the important psychosocial consequences of epilepsy in the older person.

The use of the Canadian occupational performance measure as an outcome of a pain management program

The last three decades have seen the emergence of measures to assess the efficacy of pain management programs. Recently there has been interest in measures that assess clients' perceptions of their own performance. The Canadian Occupational Performance Measure (COPM) (Law et al, 1994, 1998) is an individualized measure designed for use by occupational therapists to detect a self-perceived change in occupational performance problems over time. It may be an important extra dimension to assessing the outcomes of pain management programs. The aim of this study was to ascertain the validity of the COPM as an outcome measure for the Liverpool Pain Management Program. One hundred and six clients were recruited to the study and 87 clients completed a battery of tests including the COPM at baseline, end of program and 3 month follow-up. Results of the study demonstrated that the COPM showed good evidence of concurrent criterion validity and sensitivity to change.

Molecular dynamics ensemble, equation of state, and ergodicity

The variant of the NVE ensemble known as the molecular dynamics ensemble was recently redefined by Ray and Zhang [Phys. Rev. E 59, 4781 (1999)] to include the specification of a time invariant G (a function of phase and, explicitly, the time) in addition to the total linear momentum M. We reformulate this ensemble slightly as the NVEMR ensemble, in which R/N is the center-of-mass position, and consider the equation of state of the hard-sphere system in this ensemble through both the virial function and the Boltzmann entropy. We test the quasiergodic hypothesis by a comparison of old molecular dynamics and Monte Carlo results for the compressibility factor of the 12-particle, hard-disk systems. The virial approach, which had previously been found to support the hypothesis in the NVEM ensemble, remains unchanged in the NVEMR ensemble. The entropy S approach depends on whether S is defined through the phase integral over the energy sphere or the energy shell, the parameter straight theta being 0 or 1, respectively. The ergodic hypothesis is found to be supported for straight theta=0 but not for straight theta=1.

Lamotrigine add-on for drug-resistant partial epilepsy

BACKGROUND

Epilepsy is a common neurological disorder, affecting almost 0.5 to 1% of the population. Nearly 30% of patients with epilepsy are refractory to currently available drugs. Lamotrigine is one of the newer antiepileptic drugs and is the topic of this review.

OBJECTIVES

To examine the effects of lamotrigine on seizures, side effects, cognition and quality of life, when used as an add-on treatment for patients with drug-resistant partial epilepsy.

SEARCH STRATEGY

We searched the Cochrane Epilepsy Group trials register, the Cochrane Controlled Trials Register (Cochrane Library Issue 2, 2001), MEDLINE (January 1966 to April 2001) and reference lists of articles. We also contacted the manufacturers of lamotrigine (Glaxo-Wellcome).

SELECTION CRITERIA

Randomized placebo controlled trials, of patients with drug-resistant partial epilepsy of any age, in which an adequate method of concealment of randomization was used. The studies may be double, single or unblinded. For crossover studies, the first treatment period was treated as a parallel trial.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the trials for inclusion and extracted data. Primary analyses were by intention to treat. Outcomes included 50% or greater reduction in seizure frequency, treatment withdrawal (any reason), side effects, effects on cognition, and quality of life.

MAIN RESULTS

We found three parallel add-on studies and eight cross-over studies, which included 1243 patients (199 children and 1044 adults). The overall Peto's Odds Ratio (OR) and 95% confidence intervals (CIs) across all studies for 50% or greater reduction in seizure frequency was 2.71 (1.87, 3.91) indicating that lamotrigine is significantly more effective than placebo in reducing seizure frequency. The overall OR (95%CI) for treatment withdrawal (for any reason) is 1.12 (0.78, 1.61). The 99% CIs for ataxia, dizziness, nausea, and diplopia do not include unity, indicating that they are significantly associated with lamotrigine. The limited data available precludes any conclusions about effects on cognition and quality of life, though there may be minor benefits in affect balance (happiness) and mastery.

REVIEWER'S CONCLUSIONS

Lamotrigine add-on therapy is effective in reducing the seizure frequency, in patients with drug-resistant partial epilepsy. Further trials are needed to assess the long term effects of lamotrigine, and to compare it with other add-on drugs.

Linkage and redox isomerism in ruthenium complexes of catecholate, semiquinone, and o-acylphenolate ligands derived from 1,2-dihydroxy-9,10-anthracenedione (alizarin) and related species: syntheses, characterizations, and photophysics

The complexes Ru(CO)2L2(AL-2H) (AL = alizarin; L = PPh3, PCyc3, PBu3, P(m-NaSO3C6H4)3), Ru(CO)(dppe)(PBu3)(AL-2H), and RuH(CO)L2(AL-H) (L = PPh3, PCyc3), and Ru(CO)2L2(AR-2H) (AR = anthrarobin; L = PBu3) were prepared by reactions of Ru3(CO)12, L, and AL, and the complexes RuH(CO)(PPh3)2(AL-H), RuH(CO)(PPh3)2(QN-H) (QN = quinizarin), and RuH(CO)(PPh3)2(LQN-H) (LQN = leucoquinizarin) are prepared by reactions of RuH2(CO)(PPh3)3 with AL or QN. The AL-2H and AR-2H ligands act as 1,2-catecholates, whereas the AL-H, QN-H, LQN-H ligands are 1,9-o-acylphenolate ligands. RuH(CO)(PPh3)2(AL-H) is characterized by X-ray crystallography. The electrochemistry of these complexes is examined, and the semiquinone complexes [Ru(CO)2L2(AL-2H)]+ (L = PPh3, PCyc3, PBu3) and [Ru(CO)(dppe)(PBu3)(AL-2H)]+ are generated by chemical oxidation and were characterized by EPR and IR spectroscopy. The photophysical properties are also reported.

Extending the reach of immunoassays to optically dense specimens by using two-photon excited fluorescence polarization

Fluorescence anisotropy/polarization measurements represent a powerful tool for quantifying biomolecule/ligand complexation. These types of measurements are also at the heart of a wide variety of commercial homogeneous fluoroimmunoassays. In this note, we demonstrate the power of two-photon excited fluorescence anisotropy (2-PEFA) measurements as a tool for quantifying hapten/antibody association in the presence of a strongly absorbing, nonfluorescent dye. The results of these experiments show that 2-PEFA measurements are intrinsically more sensitive when compared to traditional one-photon excited fluorescence anisotropy (1-PEFA) strategies and 2-PEFA-based measurements allow one to perform accurate hapten/antibody binding measurements in strongly absorbing samples directly under conditions where 1-PEFA measurements fail completely. Overall, the 2-PEFA approach offers significant advantages when compared to traditional 1-PEFA methods especially in strongly absorbing samples. 2-PEFA also opens the door to perform more rapid and reliable polarization/anisotropy-based measurements with minimal sample preparation.

Quality-of-life and behavioral outcome measures in randomized controlled trials of antiepileptic drugs: a systematic review of methodology and reporting standards

PURPOSE

To review the methodology and use of quality-of-life and behavioral measures used in randomized controlled trials (RCTs) of antiepileptic drugs in patients with epilepsy.

METHODS

Trial reports were found by searching a previously developed comprehensive database of epilepsy RCTs and searching through journals by hand. Inclusion and exclusion criteria were applied, and methodological and quality-of-life and behavioral measure data were extracted.

RESULTS

There were 52 different measures used in 46 trials, with the Profile of Mood States, the Minnesota Multiphasic Personality Inventory, and the Washington Psychosocial Seizure Inventory being applied the most frequently. Overall, evidence of the reliability, validity, and sensitivity of measures used in populations of people with epilepsy was sparse. There was also little information on the clinical interpretation of the results.

CONCLUSION

Our results highlight a consistent failure to apply quality-of-life and behavioral measures in RCTs in a systematic way. We found repeated evidence of researchers' failure to review the use of previous measures and selection of measures without evidence of their appropriateness for use in a population with epilepsy. We recommend the use of quality-of-life and behavioral measures in RCTs with proven psychometric properties in a population with epilepsy.

Patient-based assessments of quality of life in newly diagnosed epilepsy patients: validation of the NEWQOL

PURPOSE

In epilepsy, patient-based assessments are increasingly used as outcome measures in clinical trials of novel therapies alongside the traditional clinical measures of efficacy. The objective of this study was to validate psychometrically a quality of life (QOL) measure developed for use with recently diagnosed epilepsy patients.

METHODS

The NEWQOL (Quality of Life in Newly Diagnosed Epilepsy Instrument) is a 93-item self-administered battery designed to assess QOL in patients with new-onset epilepsy. NEWQOL consists of eight multi-item scales (13 subscales) measuring several health parameters: Anxiety, Depression, Social Activities, Symptoms, Locus of Control/ Mastery, Neuropsychological Problems (includes the following subscales: Fatigue, Memory, Concentration, Motor Skills, and Reading), Social Stigma, Worry, Work Limitations, and several single-item measures (General Health, Number of Seizures, Social Limitations, Social Support, Self Concept, Ambition Limitations, Health Transition, and General Limitations). The NEWQOL was collected at baseline and 1 week post-baseline from 108 patients in the U.K. and U.S.

RESULTS

All of the multi-item scales had high item discriminant validity, good test-retest reliability, and acceptable levels of internal consistency reliability; all but the Reading and Stigma subscales had negligible floor and ceiling effects. General linear models were used to examine the known groups validity of NEWQOL. Significant differences were observed in the Worry, Symptoms, Summary Neuropsychological Scales, and all Neuropsychological subscales (Memory, Fatigue, Concentration, Motor Skills, and Reading), indicating poorer functioning in the more frequent or severe seizure groups.

CONCLUSIONS

Results from this study offer supportive evidence that NEWQOL has good validity and reliability and can discriminate between patient groups, particularly in relation to symptoms and psychological problems. We conclude that NEWQOL represents a useful measure for future studies in this patient population.

Effects of temperature on calcium-sensitive fluorescent probes

The effect of temperature on the binding equilibria of calcium-sensing dyes has been extensively studied, but there are also important temperature-related changes in the photophysics of the dyes that have been largely ignored. We conducted a systematic study of thermal effects on five calcium-sensing dyes under calcium-saturated and calcium-free conditions. Quin-2, chlortetracycline, calcium green dextran, Indo-1, and Fura-2 all show temperature-dependent effects on fluorescence in all or part of the range tested (5-40 degrees C). Specifically, the intensity of the single-wavelength dyes increased at low temperature. The ratiometric dyes, because of variable effects at the two wavelengths, showed, in general, a reduction in the fluorescence ratio as temperature decreased. Changes in viscosity, pH, oxygen quenching, or fluorescence maxima could not fully explain the effects of temperature on fluorescence. The excited-state lifetimes of the dyes were determined, in both the presence and absence of calcium, using multifrequency phase-modulation fluorimetry. In most cases, low temperature led to prolonged fluorescence lifetimes. The increase in lifetimes at reduced temperature is probably largely responsible for the effects of temperature on the physical properties of the calcium-sensing dyes. Clearly, these temperature effects can influence reported calcium concentrations and must therefore be taken into consideration during any investigation involving variable temperatures.

The stigma of epilepsy: a European perspective

PURPOSE

To study the stigma of epilepsy in a European sample.

METHODS

Clinical and demographic details and information about patient-perceived stigma was collected by using self-completed questionnaires mailed to members of epilepsy support groups.

RESULTS

Stigma data were collected from >5,000 patients living in 15 countries in Europe. Fifty-one percent reported feeling stigmatised, with 18% reporting feeling highly stigmatised. High scores were correlated with worry, negative feelings about life, long-term health problems, injuries, and reported side effects of antiepileptic drugs (AEDs). Cross-cultural comparisons revealed significant differences between countries. A multivariate analysis identified impact of epilepsy, age of onset, country of origin, feelings about life, and injuries associated with epilepsy as significant contributors on scores on the stigma scale.

CONCLUSIONS

This study confirms the findings of previous studies that have identified the importance of both clinical and nonclinical factors in understanding the stigma of epilepsy. The results of cross-cultural differences require further explanation, and much more research should be conducted to reduce the stigma associated with epilepsy.