The effect of historic redlining on firearm violence

BACKGROUND

Firearm homicides disproportionately affect young Black men, which in turn have lasting impact of communities of color as a whole. Previous cross-sectional studies have highlighted the role of discriminatory housing policies on the incidence of urban firearm violence. We sought to estimate the effects of racist housing policies on firearm incidence.

METHODS

Firearm incident data were obtained from the Boston Police Department and point locations spatially joined with vector files outlining the original 1930 Home Owner Loan Corporation (HOLC) Redlining maps. A regression discontinuity design was used to assess the increased rate of firearm violence crossing from historically "desirable" neighborhoods (Green) to historically "hazardous" neighborhoods (Red and Yellow) based on HOLC definitions. Linear regression models were fit on either side of the geographic boundaries with firearm incidents graphed at varying distances and the regression coefficient calculated at the boundary.

RESULTS

Crossing from desirable to Red hazardous designation there was a significant discontinuity with an increase of 4.1 firearm incidents per 1,000 people (95% CI 0.68,7.55). Similarly, when crossing from desirable areas to the Yellow hazardous designation there was a significant discontinuity and increase of 5.9 firearm incidents per 1,000 people (95% CI 1.85,9.86). There was no significant discontinuity between the two hazardous HOLC designations (coefficient -0.93, 95% CI -5.71, 3.85).

CONCLUSIONS

There is a significant increase in firearm incidents in historically redlined areas of Boston. This suggests that interventions should focus on downstream socioeconomic, demographic, and neighborhood detriments of historically discriminatory housing policies in order to address firearm homicides.

History repeats itself: Impact of mental illness on violent reinjury and hospital reencounters among female victims of interpersonal violence

BACKGROUND

Violence-related reinjury impacts both patients and health care systems. Mental illness (MI) is prevalent among violently injured individuals. The relationship between preexisting MI and violent reinjury among women has not been fully characterized. Our objective was to determine if risk of hospital reencounter-violent reinjury and all-cause-was associated with preexisting MI at time of index injury among female victims of violence.

METHODS

All females (15-100 + years) presenting to a level I trauma center with violent injury (2002-2019) surviving to discharge were included (N = 1,056). Exposure was presence of preexisting MI. The primary outcome was hospital reencounters for violent reinjury and all-cause within one year (through 2020). The secondary outcome was the development of a new MI within one year of index injury. Odds of reencounter and development of new MI for those with and without preexisting MI were compared with multivariable logistic regression, stratified for interaction when appropriate.

RESULTS

There were 404 women (38%) with preexisting MI at time of index injury. Approximately 11% of patients with preexisting MI experienced violent reinjury compared to 5% of those without within 1 year ( p < 0.001). Specifically, those with MI in the absence of concomitant substance use had more than three times the odds of violent reinjury (adjusted Odds Ratio, 3.52 (1.57, 7.93); p = 0.002). Of those with preexisting MI, 64% had at least one reencounter for any reason compared to 46% of those without ( p < 0.001 ) . Odds of all-cause reencounter for those with preexisting MI were nearly twice of those without (adjusted Odds Ratio, 1.81 [1.36, 2.42]; p < 0.0001).

CONCLUSION

Among female victims of violence, preexisting MI is associated with a significantly increased risk of hospital reencounter and violent reinjury within the first year after index injury. Recognition of this vulnerable population and improved efforts at addressing MI in trauma patients is critical to ongoing prevention efforts to reduce violent reinjury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Historic redlining, social mobility, and firearm violence

BACKGROUND

Much of the recorded medical literature focuses on individual-level factors that contribute to firearm violence. Recently, studies have highlighted higher incidence of firearm violence in historically redlined and marginalized areas, but few have gone on to study the downstream associations causing these differences. This study aims to understand the effects of historic redlining and current income mobility on firearm violence.

METHODS

Using a retrospective cross-sectional design, shooting incidents were spatially joined with redlining vector files and linked to income mobility data (how much a child makes in adulthood). Participants included all assault and homicide incidents involving a firearm in the city of Boston, between 2016 and 2019. The exposure of interest was redlining designation as outlined by the Home Owner's Loan Corporation (HOLC) in the 1930s and income mobility, stratified by race, defined as the income of a child in their 30s compared with where they grew up (census tract level). The outcome measured was shooting rate per census block.

RESULTS

We find that increases in Black income mobility (BIM) and White income mobility (WIM) are associated with significant decreases in rates of firearm incidents in all HOLC designations; however, there is a larger decrease with increasing BIM (relative risk, 0.47 per unit increase in BIM [95% confidence interval, 0.35-0.64]; relative risk, 0.81 per unit increase in WIM [95% confidence interval, 0.71-0.93]). Plotting predicted rates of firearm violence in each HOLC designation at different levels of BIM, there were no significant differences in shooting rates between historically harmful and beneficial classifications above $50,000 of BIM. Despite level of WIM, there were continued disparities between harmful and beneficial HOLC classification.

CONCLUSION

These findings highlight the importance of structural racism in the form of redlining and discriminatory housing policies, and the preclusion from economic mobility therein, on the incidence of firearm violence today.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

State firearm laws and nonfatal firearm injury-related inpatient hospitalizations: A nationwide panel study

BACKGROUND

Firearm injury remains a major cause of morbidity and mortality in the United States. Because of prior lack of comprehensive data sources, there is a paucity of literature on nonfatal firearm injury. Associations have previously been shown between state-level firearm laws and firearm fatalities, but few studies have examined the effects of these laws on nonfatal firearm hospitalization rates. Our objective was to examine the relationship between state firearm laws and firearm injury-related hospitalization rates across all 50 states over a 17-year period.

METHODS

In this panel study design, we used fixed effects multivariate regression models to analyze the relationship between 12 laws and firearm state-level injury-related hospitalization rates from 2000 to 2016 using the RAND Corporation Inpatient Hospitalizations for Firearm Injury Database. We used difference-in-differences to determine the impact of law passage in a given state compared with those states without the law, controlling for state-level covariates. The main outcome measure was the change in annual firearm injury-related inpatient hospitalization rates after passage or repeal of a state-level firearm law.

RESULTS

Examining each law individually, passage of violent misdemeanor, permitting, firearm removal from domestic violence offenders, and 10-round limit laws were associated with significant firearm injury-related hospitalization rate reductions. Examining multiple laws in the same model, passage of violent misdemeanor laws was associated with a 19.9% (confidence interval, 11.6%-27.4%) reduction, and removal of firearms from domestic violence offenders was associated with a 17.0% (confidence interval, 9.9%-23.6%) reduction in hospitalization rates.

CONCLUSION

State laws related to preventing violent offenders from possessing firearms are associated with firearm injury-related hospitalization rate reductions. Given significant physical, mental, and social burdens of nonfatal firearm injury, determining the efficacy of firearm-related policy is critical to violence and injury prevention efforts.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

Social Vulnerability and COVID-19: Changes in Trauma Activations at a Safety-Net Hospital

Introduction

Following the declaration of the COVID-19 pandemic, there were reports of decreased trauma hospitalizations, although violent crime persisted. COVID-19 has had the greatest impact on minoritized and vulnerable communities. Decreases in traumatic events may not extend to these communities, given pandemic-related socioeconomic and psychological burdens that increase the risk of exposure to trauma and violence.

Materials and methods

This was a retrospective cohort study (n = 1634) of all trauma activations presenting to our institution January 1, 2020 to May 31, 2020, and same time periods in 2018 and 2019. Census tracts and associated Social Vulnerability Index quartiles were determined from patient addresses. Changes in trauma activations pre and post Massachusetts’ state-of-emergency declaration compared to a historical control were analyzed using a difference-in-differences methodology.

Results

Weekly all-cause trauma activations fell from 26.44 to 8.25 (rate ratio = 0.36 [0.26, 0.50]) postdeclaration, with significant difference-in-differences compared to a historical control (P < 0.0001). Nonviolent trauma activations significantly decreased from 21.11 to 5.17 after the declaration (rate ratio = 0.27 [0.37, 0.91]; P < 0.0001), whereas there was no significant decrease in violent injury (5.33 to 3.08 rate ratio = 0.69 [0.39, 1.22]; P = 0.20). Stratified by vulnerability, the most vulnerable quartile had an increased proportion of all-cause trauma postdeclaration and had no decrease in violent trauma activations following the declaration compared to the historical control (rate ratio = 0.84 [0.38-1.86]; P = 0.67).

Conclusions

The state-of-emergency declaration was associated with significant decreases in overall trauma, to a greater extent in nonviolent injuries. Among those living in the most socially vulnerable communities, there was no decrease in violent trauma. These findings highlight the need for violence and injury prevention programs in vulnerable communities, particularly in times of crisis.

Historic redlining, structural racism, and firearm violence: A structural equation modeling approach

Background:

Firearm homicides disproportionately affect Black communities. Redlining – discriminatory lending practices of the early 20^th century - are associated with current increased rates of firearm violence. Poverty and concentrated disadvantage are also associated with firearm violence. The interaction of these factors with racist redlining housing practices remains unclear.

Methods:

We used generalized structural equation modeling to characterize the mediators through which redlining practices of the 1930s led to present rates of firearm violence in Boston using a negative binomial model. Principle component analysis was used to create four distinct mediating variables representing census block socioeconomic and built environment information, while reducing dimensionality. We calculated the direct effect between harmful (Red and Yellow) vs beneficial (Green) designations and firearm incident rate, indirect effect between redlining designation and firearm incident rate through each mediating variable, and the total effect. The percentage mediation of each mediator was subsequently calculated.

Findings:

Red and Yellow areas of Boston were associated with an 11•1 (95% CI 5•5,22•4) and 11•4 (5•7,22•8) increased incident rate of shooting when compared to Green. In the pathway between Red designation and firearm incident rate, poverty and poor educational attainment mediated 20% of the interaction, share of rented housing mediated 8%, and Black share of the population 3%. In the pathway between Yellow designation and firearm incident rate, poverty and poor educational attainment mediated 16% of the association, and Black share of the population mediated 13%.

Interpretation:

Redlining practices of the 1930s potentially contribute to increased rates of firearm violence through changes to neighborhood environments, namely through preclusion from homeownership, poverty, poor educational attainment, and concentration (i.e. segregation) of Black communities. These downstream mediating factors serve as points for policy interventions to address urban firearm violence.

Funding:

Michael Poulson and Miriam Neufeld were supported by T32 Training Grants (HP10028, GM86308).

COVID-19 Pandemic and the Cholecystitis Experience at a Major Urban Safety-Net Hospital

Background

Acute cholecystitis is a common reason for emergency general surgery admission. The declaration of the COVID-19 pandemic may have resulted in treatment delays and corresponding increases in severity of disease. This study compared cholecystitis admissions and disease severity pre- and postdeclaration of pandemic.

Materials and Methods

Retrospective review of adult acute cholecystitis admissions (January 1,2020-May 31, 2020). Corresponding time periods in 2018 and 2019 comprised the historical control. Difference-in-differences analysis compared biweekly cholecystitis admissions pre- and postdeclaration in 2020 to the historical control. Odds of increased severity of disease presentation were assessed using multivariable logistic regression.

Results

Cholecystitis admissions decreased 48.7% from 5.2 to 2.67 cases (RR 0.51 [0.28,0.96], P = 0.04) following pandemic declaration when comparing 2020 to historical control (P = 0.02). After stratifying by severity, only Tokyo I admissions declined significantly postdeclaration (RR 0.42 [0.18,0.97]), when compared to historical control (P = 0.02). There was no change in odds of presenting with severe disease after the pandemic declaration (aOR 1.00 [95% CI 0.30, 3.38] P < 0.99) despite significantly longer lengths of symptoms reported in mild cases.

Conclusions

Postpandemic declaration we experienced a significant decrease in cholecystitis admissions without corresponding increases in disease severity. The pandemic impacted healthcare-seeking behaviors, with fewer mild presentations. Given that the pandemic did not increase odds of presenting with increased severity of disease, our data suggests that not all mild cases of cholecystitis progress to worsening disease and some may resolve without medical or surgical intervention.

Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture utilizing the Istanbul Protocol

Despite being a common form of abuse, there is a paucity of literature describing shackling and wrist restraint injuries among survivors of torture. Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture presents challenges to the evaluator, especially if the injuries are remote and do not leave lasting marks nor neurologic deficits. Thorough history-taking and physical examination are critical to effective forensic documentation. Guidance is provided in The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol), the gold standard for the medicolegal documentation of torture. This guidance relies primarily on physical findings, with less direction provided on how to interpret historical evidence or when historical evidence provided by the patient can be interpreted as highly consistent with alleged injury in the absence of current physical findings. Through a case-based review, we present diagnostic strategies for the evaluation of alleged abuse involving wrist restraints/handcuffs, focusing on skin, neurologic, and osseous injuries. We highlight key findings from both the history and physical examination that will allow the evaluator to improve the accuracy of their expert medical opinion on the degree to which medical findings correlate with the patient's allegations of wrist restraint injuries.

Utilization of mental health services in pediatric patients surviving penetrating trauma resulting from interpersonal violence

BACKGROUND

Violent trauma has lasting psychological impacts. Our institution's Community Violence Response Team (CVRT) offers mental health services to trauma victims. We characterized implementation and determined factors associated with utilization by pediatric survivors of interpersonal violence-related penetrating trauma.

METHODS

Analysis included survivors (0-21 years) of violent penetrating injury at our institution (2011-2017). Injury and demographic data were collected. Nonparametric regression models determined factors associated with utilization.

RESULTS

There was initial rapid uptake of CVRT (2011-2013) after which it plateaued, serving >80% of eligible patients (2017). White race and higher injury severity were associated with receipt and duration of services. In post-hoc analysis, race was found to be associated with continued treatment but not with initial consultation.

CONCLUSION

Successful implementation required three years, aiding >80% of patients. CVRT is a blueprint to strengthen existing violence intervention programs. Efforts should be made to ensure that barriers to providing care, including those related to race, are overcome.

Where did the patients go? Changes in acute appendicitis presentation and severity of illness during the coronavirus disease 2019 pandemic: A retrospective cohort study

BACKGROUND

The coronavirus disease 2019 pandemic restricted movement of individuals and altered provision of health care, abruptly transforming health care-use behaviors. It serves as a natural experiment to explore changes in presentations for surgical diseases including acute appendicitis. The objective was to determine if the pandemic was associated with changes in incidence of acute appendicitis compared to a historical control and to determine if there were associated changes in disease severity.

METHODS

The study is a retrospective, multicenter cohort study of adults (N = 956) presenting with appendicitis in nonpandemic versus pandemic time periods (December 1, 2019-March 10, 2020 versus March 11, 2020-May 16, 2020). Corresponding time periods in 2018 and 2019 composed the historical control. Primary outcome was mean biweekly counts of all appendicitis presentations, then stratified by complicated (n = 209) and uncomplicated (n = 747) disease. Trends in presentations were compared using difference-in-differences methodology. Changes in odds of presenting with complicated disease were assessed via clustered multivariable logistic regression.

RESULTS

There was a 29% decrease in mean biweekly appendicitis presentations from 5.4 to 3.8 (rate ratio = 0.71 [0.51, 0.98]) after the pandemic declaration, with a significant difference in differences compared with historical control (P = .003). Stratified by severity, the decrease was significant for uncomplicated appendicitis (rate ratio = 0.65 [95% confidence interval 0.47-0.91]) when compared with historical control (P = .03) but not for complicated appendicitis (rate ratio = 0.89 [95% confidence interval 0.52-1.52]); (P = .49). The odds of presenting with complicated disease did not change (adjusted odds ratio 1.36 [95% confidence interval 0.83-2.25]).

CONCLUSION

The pandemic was associated with decreased incidence of uncomplicated appendicitis without an accompanying increase in complicated disease. Changes in individual health care-use behaviors may underlie these differences, suggesting that some cases of uncomplicated appendicitis may resolve without progression to complicated disease.

Firearm Policy: Physician Organizations' Role in Political Action Committee Funds, 2018

Objectives. To compare donations to individual politicians from physician organization political action committees (PACs) and from the National Rifle Association Political Victory Fund (NRA PVF) in 2018.Methods. We identified 7 organizations with published firearm injury prevention policy. We determined the difference in funds received from physician organization PACs and the NRA PVF for each congressmember. We examined their voting records on firearm-related legislation.Results. A total of 141 congressmembers received funds from both physician organization PACs and the NRA PVF. Of these, 99.3% voted for legislation not consistent with organization recommendations. The majority (70.2%) received more funds from the combined physician organization PACs than from the NRA PVF.Conclusions. Physician organization PACs have a financial impact on NRA-backed congressmembers. They currently contribute to politicians with voting records inconsistent with their own policy recommendations. Firearm violence prevention does not currently outweigh other legislative priorities for physician organization PAC contributions.

Probabilistic machine learning for the evaluation of presurgical language dominance

OBJECTIVE

Providing a reliable assessment of language lateralization is an important task to be performed prior to neurosurgery in patients with epilepsy. Over the last decade, functional MRI (fMRI) has emerged as a useful noninvasive tool for language lateralization, supplementing or replacing traditional invasive methods. In standard practice, fMRI-based language lateralization is assessed qualitatively by visual inspection of fMRI maps at a specific chosen activation threshold. The purpose of this study was to develop and evaluate a new computational technique for providing the probability of each patient to be left, right, or bilateral dominant in language processing.

METHODS

In 76 patients with epilepsy, a language lateralization index was calculated using the verb-generation fMRI task over a wide range of activation thresholds (from a permissive threshold, analyzing all brain regions, to a harsh threshold, analyzing only the strongest activations). The data were classified using a probabilistic logistic regression method.

RESULTS

Concordant results between fMRI and Wada lateralization were observed in 89% of patients. Bilateral and right-dominant groups showed similar fMRI lateralization patterns differentiating them from the left-dominant group but still allowing classification in 82% of patients.

CONCLUSIONS

These findings present the utility of a semi-supervised probabilistic learning approach for presurgical language-dominance mapping, which may be extended to other cognitive domains such as memory and attention.

Multiplex families with epilepsy: Success of clinical and molecular genetic characterization

OBJECTIVE

To analyze the clinical syndromes and inheritance patterns of multiplex families with epilepsy toward the ultimate aim of uncovering the underlying molecular genetic basis.

METHODS

Following the referral of families with 2 or more relatives with epilepsy, individuals were classified into epilepsy syndromes. Families were classified into syndromes where at least 2 family members had a specific diagnosis. Pedigrees were analyzed and molecular genetic studies were performed as appropriate.

RESULTS

A total of 211 families were ascertained over an 11-year period in Israel. A total of 169 were classified into broad familial epilepsy syndrome groups: 61 generalized, 22 focal, 24 febrile seizure syndromes, 33 special syndromes, and 29 mixed. A total of 42 families remained unclassified. Pathogenic variants were identified in 49/211 families (23%). The majority were found in established epilepsy genes (e.g., SCN1A, KCNQ2, CSTB), but in 11 families, this cohort contributed to the initial discovery (e.g., KCNT1, PCDH19, TBC1D24). We expand the phenotypic spectrum of established epilepsy genes by reporting a familial LAMC3 homozygous variant, where the predominant phenotype was epilepsy with myoclonic-atonic seizures, and a pathogenic SCN1A variant in a family where in 5 siblings the phenotype was broadly consistent with Dravet syndrome, a disorder that usually occurs sporadically.

CONCLUSION

A total of 80% of families were successfully classified, with pathogenic variants identified in 23%. The successful characterization of familial electroclinical and inheritance patterns has highlighted the value of studying multiplex families and their contribution towards uncovering the genetic basis of the epilepsies.

Long-term video-EEG in patients with frontal seizures

The interictal epileptiform discharge (IED) yield of long-term video-EEG (LTVEEG) monitoring is increased compared to a single out-patient EEG, but was not studied specifically in frontal lobe epilepsy. Since IED recording can influence the length of monitoring when seizures are not recorded during LTVEEG, we aimed to assess the IED yield of LTVEEG recording in patients with frontal seizures. We retrospectively reviewed the medical records of 20 patients with frontal seizures during non-invasive LTVEEG in Tel Aviv Medical Center between 2003 and 2008 and compared them with the results of out-patient EEG. The study group included 11 (55%) men and 9 women aged 15-82 years (mean: 27 years). LTVEEG duration ranged between 4 and 29 days (mean: 14 days). IEDs were detected by each of the tests in eight (40%) patients. We conclude that non-invasive LTVEEG and out-patient EEG have a similar diagnostic yield for IEDs in patients with frontal seizures. Therefore, seizures remain the most relevant clinical outcome of LTVEEG.

Mild adolescent/adult onset epilepsy and paroxysmal exercise-induced dyskinesia due to GLUT1 deficiency

Paroxysmal exercise-induced dyskinesia (PED) and epilepsy without intellectual disability have recently been recognized as manifestations of deficiency of the glucose transporter GLUT1, due to mutations in the gene SLC2A1. We describe a family with six definitely affected members in two generations. Two had PED, three had epilepsy, and one had both. A missense mutation in SLC2A1 (c.950A>C; p.N317T) was detected in five living affected members, but absent in three nonaffected first-degree members and in one subject believed to be a phenocopy. The clinical picture of mild epilepsy with onset in adolescence or early adulthood plus PED should raise a suspicion of GLUT1 deficiency.

SCN1A duplications and deletions detected in Dravet syndrome: implications for molecular diagnosis

OBJECTIVE

We aimed to determine the type, frequency, and size of microchromosomal copy number variations (CNVs) affecting the neuronal sodium channel α 1 subunit gene (SCN1A) in Dravet syndrome (DS), other epileptic encephalopathies, and generalized epilepsy with febrile seizures plus (GEFS+).

METHODS

Multiplex ligation-dependent probe amplification (MLPA) was applied to detect SCN1A CNVs among 289 cases (126 DS, 97 GEFS+, and 66 with other phenotypes). CNVs extending beyond SCN1A were further characterized by comparative genome hybridization (array CGH).

RESULTS

Novel SCN1A CNVs were found in 12.5% of DS patients where sequence-based mutations had been excluded. We identified the first partial SCN1A duplications in two siblings with typical DS and in a patient with early-onset symptomatic generalized epilepsy. In addition, a patient with DS had a partial SCN1A amplification of 5-6 copies. The remaining CNVs abnormalities were four partial and nine whole SCN1A deletions involving contiguous genes. Two CNVs (a partial SCN1A deletion and a duplication) were inherited from a parent, in whom there was mosaicism. Array CGH showed intragenic deletions of 90 kb and larger, with the largest of 9.3 Mb deleting 49 contiguous genes and extending beyond SCN1A.

DISCUSSION

Duplication and amplification involving SCN1A are now added to molecular mechanisms of DS patients. Our findings showed that 12.5% of DS patients who are mutation negative have MLPA-detected SCN1A CNVs with an overall frequency of about 2-3%. MLPA is the established second-line testing strategy to reliably detect all CNVs of SCN1A from the megabase range down to one exon. Large CNVs extending outside SCN1A and involving contiguous genes can be precisely characterized by array CGH.

A homozygous mutation in human PRICKLE1 causes an autosomal-recessive progressive myoclonus epilepsy-ataxia syndrome

Progressive myoclonus epilepsy (PME) is a syndrome characterized by myoclonic seizures (lightning-like jerks), generalized convulsive seizures, and varying degrees of neurological decline, especially ataxia and dementia. Previously, we characterized three pedigrees of individuals with PME and ataxia, where either clinical features or linkage mapping excluded known PME loci. This report identifies a mutation in PRICKLE1 (also known as RILP for REST/NRSF interacting LIM domain protein) in all three of these pedigrees. The identified PRICKLE1 mutation blocks the PRICKLE1 and REST interaction in vitro and disrupts the normal function of PRICKLE1 in an in vivo zebrafish overexpression system. PRICKLE1 is expressed in brain regions implicated in epilepsy and ataxia in mice and humans, and, to our knowledge, is the first molecule in the noncanonical WNT signaling pathway to be directly implicated in human epilepsy.

Postmeningitis headache

Acute meningitis is associated with headache, but the natural history of the headache following recovery is unknown. We addressed this issue in 141 patients admitted during 1990 to 1993 with laboratory-confirmed meningitis. We excluded patients younger than 5 years (n=44), elderly demented patients (n=6), and those with potential causes of headache other than meningitis (n=4). Seventeen candidates could not be traced. The remaining 70 patients were interviewed using a semistructured questionnaire that documented age, sex, type of meningitis, time of headache onset after infection, and headache description as well as any past and/or family history of headache. These patients were compared to age- and sex-matched controls (n=70). Prior to meningitis, 13 patients (19%) had had headaches (migrainous in 8) as did 18 controls (26%; migrainous in 8). Headache first appeared after meningitis in 19 patients (33%; migrainous in 6), increasing the total prevalence to 46%. We found no association between sex, type of meningitis, or family history and the development of postmeningitis headache. Patients who developed postmeningitis headache were significantly younger than those who did not. We conclude that there is an association between meningitis, either bacterial or aseptic, and subsequent persistent recurrent migrainous or nonmigrainous headache.

Possible remote functional reorganization in left temporal lobe epilepsy

OBJECTIVE

To provide functional magnetic resonance imaging-based insight into the impact of left temporal lobe epilepsy (TLE) on language-related functional re-organization.

MATERIALS AND METHODS

Ten right-handed patients with left TLE were compared with 10 matched healthy controls. Regional brain activation during the language task was measured in the inferior frontal gyrus (IFG) and in the superior temporal gyrus (STG), and the regional inter-hemispheric lateralization index (LI) was calculated.

RESULTS

Left language lateralization was documented in all the patients and controls. Reduced lateralization in the IFG was due to decreased activity in the left frontal region rather than to increased activity in the right frontal region. The LI values in the STG correlated with the LI values in the IFG in the controls but not in the patients.

CONCLUSIONS

The left IFG was most probably involved in the epileptogenesis and concomitant language-related cortical plasticity in patients with left TLE.

Epilepsy and mental retardation limited to females: an under-recognized disorder

Epilepsy and Mental Retardation limited to Females (EFMR) which links to Xq22 has been reported in only one family. We aimed to determine if there was a distinctive phenotype that would enhance recognition of this disorder. We ascertained four unrelated families (two Australian, two Israeli) where seizures in females were transmitted through carrier males. Detailed clinical assessment was performed on 58 individuals, using a validated seizure questionnaire, neurological examination and review of EEG and imaging studies. Gene localization was examined using Xq22 microsatellite markers. Twenty-seven affected females had a mean seizure onset of 14 months (range 6-36) typically presenting with convulsions. All had convulsive attacks at some stage, associated with fever in 17 out of 27 (63%). Multiple seizure types occurred including tonic-clonic (26), tonic (4), partial (11), absence (5), atonic (3) and myoclonic (4). Seizures ceased at mean 12 years. Developmental progress varied from normal (7), to always delayed (4) to normal followed by regression (12). Intellect ranged from normal to severe intellectual disability (ID), with 67% of females having ID or being of borderline intellect. Autistic (6), obsessive (9) and aggressive (7) features were prominent. EEGs showed generalized and focal epileptiform abnormalities. Five obligate male carriers had obsessional tendencies. Linkage to Xq22 was confirmed (maximum lod 3.5 at = 0). We conclude that EFMR is a distinctive, under-recognized familial syndrome where girls present with convulsions in infancy, often associated with intellectual impairment and autistic features. The unique inheritance pattern with transmission by males is perplexing. Clinical recognition is straightforward in multiplex families due to the unique inheritance pattern; however, this disorder should be considered in smaller families where females alone have seizures beginning in infancy, particularly in the setting of developmental delay. In single cases, diagnosis will depend on identification of the molecular basis.

Long-term tetrahydroaminoacridine treatment and quantitative EEG in Alzheimer's disease

The development of therapies for Alzheimer's disease (AD) has focused on drugs designed to correct the loss of cholinergic function within the central nervous system. Quantitative EEG (qEEG) changes associated with AD consist of background slowing. One way to study the effects of cholinergic drugs may be through assessment of their qEEG effects. The aim of the current work was to evaluate the effect of long-term treatment with tetrahydroaminoacridine (THA) on qEEG in AD patients.

Video-EEG monitoring of paroxysmal events in the elderly

OBJECTIVES

To determine the importance of video-EEG monitoring (VEM) in elderly patients with various paroxysmal events.

MATERIAL AND METHODS

We retrospectively identified 16 subjects > or = 60 years old out of 834 (1.9%; 7 females, mean age 67.8 +/- 7.7 years), who were admitted to the Video-EEG Unit between 1997 and 2005 and compared data between those with and without epileptic events.

RESULTS

Epilepsy was confirmed in six patients, psychogenic non-epileptic seizures (NES) were diagnosed in seven, one patient had NES and epilepsy whereas the recorded events were non-conclusive in two. NES patients had a higher predisposition to psychiatric disturbances (P<0.02). Following VEM and management alteration, the frequency of monthly events decreased significantly for the cohort as a whole (P<0.001). VEM directly influenced the diagnosis, treatment and outcome of 14 of 16 (88%) patients.

CONCLUSION

Video-EEM plays a vital role in the evaluation of paroxysmal events in the elderly, but is vastly underutilized in this population group.

Is there any correlation between severity of epilepsy and cognitive abilities in patients with temporal lobe epilepsy?

Frequent refractory seizures may cause cognitive deterioration when they present at an early age, especially in infants. The findings of previous studies designed to examine the impact of repetitive seizures on cognition in adolescents and adults, however, have shown wide variation. We analyzed the data of neuropsychological evaluations of patients before they underwent temporal lobe resection because of refractory seizure disorder in our institution from 1998 to 2001. Forty-four consecutive patients aged 12-48 years underwent a comprehensive neuropsychological evaluation that included a battery of selected visual and verbal memory tests. Statistical analysis revealed no significant correlation between disease-related parameters, such as age of onset, duration of active disease, estimated cumulative number of complex partial seizures and secondarily generalized seizures, and the results of neuropsychological tests. These findings support the hypothesis that factors other than repetitive seizures are responsible for cognitive dysfunction among adolescents and adults.

A new clinical and molecular form of Unverricht-Lundborg disease localized by homozygosity mapping

Progressive myoclonus epilepsy (PME) has a number of causes, of which Unverricht-Lundborg disease (ULD) is the most common. ULD has previously been mapped to a locus on chromosome 21 (EPM1). Subsequently, mutations in the cystatin B gene have been found in most cases. In the present work we identified an inbred Arab family with a clinical pattern compatible with ULD, but mutations in the cystatin B gene were absent. We sought to characterize the clinical and molecular features of the disorder. The family was studied by multiple field trips to their town to clarify details of the complex consanguineous relationships and to personally examine the family. DNA was collected for subsequent molecular analyses from 21 individuals. A genome-wide screen was performed using 811 microsatellite markers. Homozygosity mapping was used to identify loci of interest. There were eight affected individuals. Clinical onset was at 7.3 +/- 1.5 years with myoclonic or tonic-clonic seizures. All had myoclonus that progressed in severity over time and seven had tonic-clonic seizures. Ataxia, in addition to myoclonus, occurred in all. Detailed cognitive assessment was not possible, but there was no significant progressive dementia. There was intrafamily variation in severity; three required wheelchairs in adult life; the others could walk unaided. MRI, muscle and skin biopsies on one individual were unremarkable. We mapped the family to a 15-megabase region at the pericentromeric region of chromosome 12 with a maximum lod score of 6.32. Although the phenotype of individual subjects was typical of ULD, the mean age of onset (7.3 years versus 11 years for ULD) was younger. The locus on chromosome 12 does not contain genes for any other form of PME, nor does it have genes known to be related to cystatin B. This represents a new form of PME and we have designated the locus as EPM1B.

Genetic Architecture of Idiopathic Generalized Epilepsy: Clinical Genetic Analysis of 55 Multiplex Families

PURPOSE

In families with idiopathic generalized epilepsy (IGE), multiple IGE subsyndromes may occur. We performed a genetic study of IGE families to clarify the genetic relation of the IGE subsyndromes and to improve understanding of the mode(s) of inheritance.

METHODS

Clinical and genealogic data were obtained on probands with IGE and family members with a history of seizures. Families were grouped according to the probands' IGE subsyndrome: childhood absence epilepsy (CAE), juvenile absence epilepsy (JAE), juvenile myoclonic epilepsy (JME), and IGE with tonic-clonic seizures only (IGE-TCS). The subsyndromes in the relatives were analyzed. Mutations in genes encoding alpha1 and gamma 2 gamma-aminobutyric acid (GABA)-receptor subunits, alpha1 and beta1 sodium channel subunits, and the chloride channel CLC-2 were sought.

RESULTS

Fifty-five families were studied. 122 (13%) of 937 first- and second-degree relatives had seizures. Phenotypic concordance within families of CAE and JME probands was 28 and 27%, respectively. JAE and IGE-TCS families had a much lower concordance (10 and 13%), and in the JAE group, 31% of relatives had CAE. JME was rare among affected relatives of CAE and JAE probands and vice versa. Mothers were more frequently affected than fathers. No GABA-receptor or sodium or chloride channel gene mutations were identified.

CONCLUSIONS

The clinical genetic analysis of this set of families suggests that CAE and JAE share a close genetic relation, whereas JME is a more distinct entity. Febrile seizures and epilepsy with unclassified tonic-clonic seizures were frequent in affected relatives of all IGE individuals, perhaps representing a nonspecific susceptibility to seizures. A maternal effect also was seen. Our findings are consistent with an oligogenic model of inheritance.

LGI1mutations in temporal lobe epilepsies

BACKGROUND AND OBJECTIVES

A number of familial temporal lobe epilepsies (TLE) have been recently recognized. Mutations in LGI1 (leucine-rich, glioma-inactivated 1 gene) have been found in a few families with the syndrome of autosomal dominant partial epilepsy with auditory features (ADPEAF). The authors aimed to determine the spectrum of TLE phenotypes with LGI1 mutations, to study the frequency of mutations in ADPEAF, and to examine the role of LGI1 paralogs in ADPEAF without LGI1 mutations.

METHODS

The authors performed a clinical and molecular analysis on 75 pedigrees comprising 54 with a variety of familial epilepsies associated with TLE and 21 sporadic TLE cases. All were studied for mutations in LGI1. ADPEAF families negative for LGI1 mutations were screened for mutations in LGI2, LGI3, and LGI4.

RESULTS

Four families had ADPEAF, 22 had mesial TLE, 11 had TLE with febrile seizures, two had TLE with developmental abnormalities, and 15 had various other TLE syndromes. LGI1 mutations were found in two of four ADPEAF families, but in none of the other 50 families nor in the 21 individuals with sporadic TLE. The mutations were novel missense mutations in exons 1 (c.124T-->G; C42G) and 8 (c.1418C-->T; S473L). No mutations in LGI2, LGI3, or LGI4 were found in the other two ADPEAF families.

CONCLUSION

In TLE, mutations in LGI1 are specific for ADPEAF but do not occur in all families. ADPEAF is genetically heterogeneous, but mutations in LGI2, LGI3, or LGI4 did not account for families without LGI1 mutations.

Cortical lesions associated with transient neurological symptoms - not always a matter of cause and effect

The occurrence of transient recurrent stereotypical neurological events mandates the exclusion of an underlying brain lesion. When imaging studies demonstrate the presence of a structural brain lesion, a cause and effect relationship between the two entities is assumed, and the decision for surgical intervention may then follow almost automatically. We describe five patients with transient neurological events suspected as being seizures that were referred for surgery because of an associated structural brain lesion. Video electroencephalographic recordings revealed that the events that brought these patients to neurosurgical attention were non-epileptic seizures. None of these patients underwent surgical intervention, and all were referred for behavioral therapy. Therefore, even in the presence of a confirmed brain lesion, the presenting paroxysmal events may be of a non-organic origin and should not necessarily be assumed to be caused by the concomitantly existing structural abnormality.

Anti-epileptic drugs as possible neuroprotectants in cerebral ischemia

Many similarities exist between cerebral ischemia and epilepsy regarding brain-damaging and auto-protective mechanisms that are activated following the injurious insult. Therefore, drugs that are effective in minimizing seizure-induced brain damage may also be useful in minimizing ischemic injury. Use of such drugs in stroke victims may have important clinical and financial advantages. Therefore, the authors conducted a Medline search of studies involving the use of anti-epileptic drugs (AEDs) as possible neuroprotectants and summarize the data. Most AEDs have been tested in animal models of focal or global ischemia and some were already tested in humans, for a possible neuroprotective effect. The existing data is rather scant and insufficient but it appears that only drugs that have multiple mechanisms of action seem to have some potential in conferring a degree of neuroprotection that could be clinically applicable to stroke patients. In conclusion, some of the newer AEDs show promise as possible neuroprotectants in the setup of acute ischemic stroke but more studies are needed before clinical trials in humans could be undertaken.

Effects of rivastigmine on the quantitative EEG in demented Parkinsonian patients

OBJECTIVES

Quantitative electroencephalogram (qEEG) can be used to measure the effects of drugs on the brain. We studied the effects of rivastigmine on the qEEG in Parkinson's disease (PD) patients with dementia.

SUBJECTS AND METHODS

Demented PD patients (n=19) were treated with rivastigmine in an open label study. Recordings were obtained prior to and following 12 weeks of treatment. Results were analyzed using two-way ANOVA with repeated measures.

RESULTS

A significant increase in the relative alpha (P < 0.05) activity was observed after treatment with rivastigmine. This was general rather than localized to specific brain surface areas. An increase in beta activity and decrease in the slower frequencies (delta and theta) were also observed; however, these were not statistically significant.

CONCLUSION

qEEG may serve as an objective tool to monitor the effects of antidementia drug therapy. The changes characterized by increased faster frequencies and decreased slower frequencies that were observed may indicate increased arousal or improvement in the cognitive state of the patients as a consequence of the treatment with rivastigmine.

Prevalence and clinical features of dementia associated with the antiphospholipid syndrome and circulating anticoagulants

The increasing prevalence with age of antiphospholipid antibodies (aPL), of dementia and of stroke complicates the study of a causal relationship between antiphospholipid syndrome (APS) and dementia. Prolonged aPTT due to circulating anticoagulants (CAC) may serve as a more specific laboratory marker of APS. In a hospital-based study, we examined all patients with CAC and included 23 who fulfilled standard criteria for primary APS. These patients were assessed for dementia, vascular brain disease, autoimmune disease activity and dementia risk factors. Among CAC-positive APS patients, 13 of the 23 (56%) were demented and these were significantly older (mean age+/-S.E., 68+/-3 years) than the nondemented APS group (n=10, 51+/-4 years; p<0.01, Student's t-test). The demented patients had significantly more pathology on computerized brain tomography (CT) and electroencephalography (EEG) studies but six of them had no clinical or CT evidence of vascular brain disease. Erythrocyte sedimentation rate was significantly lower in the dementia group, in which there was also a significant negative correlation between levels of aPL and age. CAC-positive APS patients seem to be at risk for developing dementia with age, suggesting a pathogenic role for prolonged exposure to elevated aPL.

EEG changes during long-term treatment with donepezil in Alzheimer's disease patients

In this pilot study, we examined the long-term treatment effect of donepezil on the quantitative EEG (qEEG) in 12 Alzheimer's disease patients. The qEEGs of the mean absolute and relative amplitudes of betal, alpha, theta and delta activities were obtained at baseline and during donepezil treatment. Comparisons of awake qEEG prior to and during treatment were performed using a 2-way analysis of variance (ANOVA) with repeated measures. In patients with mild dementia (n = 5), the qEEG analysis showed a significant reduction of the mean absolute theta activity (p = 0.05) by donepezil, particularly in frontal and temporo-parietal areas. In patients with moderate/severe dementia (n = 7), a significant decrease in the mean absolute beta 1 activity (p = 0.02), particularly in the frontal and occipital areas may be attributed to disease progression which was not counteracted by the long-term treatment. The differences in qEEG in patients with different stages of dementia under donepezil treatment may be related to different compensatory capacities due to structural and functional brain disturbances.

Unverricht-Lundborg disease in a five-generation Arab family: instability of dodecamer repeats

BACKGROUND

Unverricht-Lundborg disease (ULD) is the prototypical form of progressive myoclonus epilepsy, and subjects are usually very photosensitive. ULD is caused by mutations in the cystatin B (CSTB) gene; the most common mutation is expansion of a dodecamer repeat near the promoter. The authors studied a five-generation Arab family with ULD lacking photosensitivity.

METHODS

An Arab family from the Galilee region of Israel with progressive myoclonus epilepsy was clinically evaluated. Blood samples were obtained from three living affected and 16 unaffected individuals. Expansion of dodecamer repeat in the CSTB gene was examined.

RESULTS

The three living affected individuals showed spontaneous and action myoclonus, ataxia, and mild dementia. EEG in two individuals showed generalized polyspike-wave without photosensitivity. The family structure with large sibships and multiple consanguineous loops allowed the authors to examine the gene over four generations of adults. The three living affected individuals were homozygous for repeat expansions and 11 of the 16 unaffected family members were heterozygous. Instability was demonstrated by the presence of expansions of different sizes occurring on the same haplotype background in this inbred family. Fragment size variations could be unequivocally detected in two sibships. The expansions were in the 49 to 54 dodecamer repeat range. Changes in one generation were small, 1 to 4 repeat units, consisting of either enlargements or contractions.

CONCLUSIONS

Instability of the expanded dodecamer repeats in the cystatin B gene is frequent. Almost invariably, a small change is observed in parent-child transmission. The lack of photosensitivity in this family is unexplained.

Quality of life self-assessment as a function of lateralization of lesion in candidates for epilepsy surgery

PURPOSE

This prospective study aimed to investigate the relationship(s) of the laterality of the epileptogenic lesion to personality factors, emotional processing, and the subjective experience of quality-of-life (QOL) self-assessment in candidates for epilepsy surgery.

METHODS

Patients who were candidates for epilepsy surgery were studied. Eighteen of them (aged 19-61 years) had localization-related epilepsy in the right temporal lobe (RTLE), 18 (aged 21-50 years) had localization-related epilepsy in the left temporal lobe (LTLE), and 20 were demographically matched normal subjects. The Spielberger Trait/State Anxiety questionnaire and the QOLIE-31 questionnaire for self-assessment of quality of life were used. One-way analysis of variance, Pearson correlations, and linear regression analyses were performed on group and anxiety levels and QOLIE variables.

RESULTS

LTLE patients systematically showed higher levels of anxiety and lower self-estimates of the quality of their lives when compared with RTLE patients. All anxiety measures were highly correlated with Total QOL in LTLE (p < 0.05) but not in RTLE patients; however, different parameters of QOL showed different relationships with measures of anxiety. Results of multiple regression analyses suggested that the level of anxiety was relatively stable and less affected by QOL factors in LTLE as compared with RTLE patients (p = 0.03).

CONCLUSIONS

A high level of anxiety shown by LTLE patients may represent a personality trait and cause a response bias in overreporting of negative symptoms and a decreased self-assessment of QOL. It may also present a presurgical risk factor, particularly for patients with LTLE lesions. Appropriate patient counseling is advised.

Physically traumatic events in patients with epilepsy compared with non-epileptic subjects

To determine the incidence of traumatic events among epileptic patients compared with non-epileptic individuals, we distributed a questionnaire on physically traumatic events occurring during the preceding three months to consecutive epileptic patients and to age- and sex-matched controls. There were 145 epileptic patients, 121 with seizures (age 36 +/- 15 y, 60 males) and 24 who were seizure free during this period (age 39 +/- 17 y, 13 males), and 145 controls (age 36 +/- 15 y, 73 males). There was no significant difference in the duration of epilepsy between the two groups of patients with epilepsy. Traumatic events (n= 27, three of them unrelated to seizure) were most common in patients with seizures, followed by controls (n= 20), and absent in seizure-free patients (P< 0.001). Patients with epilepsy most commonly injured the head while the extremities were more usually involved in controls. Patients with epilepsy had significantly more traumatic events at home, whereas controls underwent most traumatic events at work and in public areas. There was no significant difference in the type and severity of trauma between the two groups. We conclude that physically traumatic events not related to seizures are fewer among patients with epilepsy with and without seizures compared with controls, probably because of increased cautiousness.

The diagnostic aid of routine EEG findings in patients presenting with a presumed first-ever unprovoked seizure

Data are available on the yield of a single EEG recording in patients with epilepsy but there is little information on EEG findings as an aid in supporting the diagnosis of an epileptic event in patients presenting with a first-ever event suspected of being an unprovoked seizure. We retrieved files of patients above the age of 15 years admitted through the emergency room during 1991-1995 with presumed first-ever unprovoked seizure. There were 91 patients (age 50+/-24; 52 males), of whom 66% had a presumed seizure of unknown origin and 34% had presumed remote symptomatic seizures. About 80% had generalized seizures (primarily or secondarily). In all the patients an EEG had been performed within 48 h of the event. Abnormal EEGs were obtained in 69%, with epileptiform activity in 21% (10% focal, 9% generalized and 2% focal and generalized), slowing in 58% (21% focal, 31% generalized and 7% focal and generalized), and both epileptiform activity and slowing in 10%. Epileptiform activity was most common in younger patients with seizures of unknown origin, compared with older individuals with symptomatic seizures (34, 38 vs. 27%, 7%, P=0.001). We conclude that following a single unprovoked presumed seizure, adults commonly exhibit abnormalities in an EEG recorded close in time to the event. The EEG is particularly helpful in supporting the epileptic nature of the event in younger patients and in those with seizures of unknown origin.

Thallium poisoning in Israel

We report the first case of thallium poisoning in Israel in almost 30 years. A 40-year-old man was apparently poisoned by a business associate when, on several occasions, he unknowingly drank an alcoholic beverage containing the toxic substance. Delayed admission and recurrent thallium ingestion resulted in both acute and chronic symptoms being present concomitantly. Conventional treatment modalities (Prussian blue and forced diuresis) were employed. The patient survived, although neurological sequelae ensued. The problems encountered in diagnosis and treatment of this relatively uncommon entity are discussed.

[Phenobarbital coma for psychogenic status epilepticus]

Among patients seen for epileptic seizures, there is a subgroup of those who do not have epilepsy but suffer from psychogenic paroxysmal events which mimic epileptic seizures. The differential diagnosis between them is of the utmost importance, as incorrect diagnosis of seizures subjects the patient to incorrect management. In the case psychogenic status epilepticus, the treatment may endanger the patient. We report 3 women, aged 20, 20 and 28 and a man aged 24 with psychogenic status epilepticus admitted to an intensive care unit and treated by induction of phenobarbital coma when other antiepileptic medication failed.

Life-long history of injuries related to seizures

There is meager information in the literature regarding the characteristics and risk factors for injuries caused during epileptic seizures in adults. Previous studies focused mainly on specific types of injuries incurred, and only few explored associated risk factors. A questionnaire regarding lifetime seizures and their traumatic consequences was administered to 298 consecutive epileptic patients and their caretakers or relatives. Ninety-one of them (30%) have reported trauma: 185 events (age 39.8+/-18 years, 54 males), of which 61 were severe. This translates to one seizure-related injury every 21 patient-years, and a serious injury once every 64 patient-years. The most common site of injury was the head (55% of the events). Blunt injuries occurred most frequently (40%), followed by cuts (28%). Severe injuries included fractures and dislocations (17%), burns (6%), brain concussion (6%), subdural hematoma (3%) and intracerebral hematoma (1%). Most injuries occurred at home. The 91 patients with traumatic events were compared with the 207 epileptic patients without previous trauma (age 37.8+/-14.7 years, 112 males). Patients with seizure-related trauma had significantly earlier onset age of epilepsy. They more commonly had generalized from onset tonic-clonic, complex partial, myoclonic or absence seizures but fewer had partial seizures with secondary generalization. The risk of trauma was mostly related to seizure type (generalized tonic clonic from onset and myoclonic seizures). This information may be helpful for better management of epileptic patients.

Intermittent rhythmic delta activity (IRDA) morphology cannot distinguish between focal and diffuse brain disturbances

IRDA (intermittent rhythmic delta activity) is an abnormal generalized EEG pattern that is not specific to any single etiology and can occur with diffuse or focal cerebral disturbances. To determine whether different electrographic features of IRDA and associated EEG findings can differentiate underlying focal from diffuse brain disturbances, we performed a blind analysis of 58 consecutive EEGs with an IRDA pattern, recorded from 1993 until 1996, in which we evaluated posterior background activity, focal slowing and IRDA characteristics (frequency, distribution, duration, symmetry and abundance). The clinical diagnosis, state of consciousness and CT brain findings were retrieved from the patients' hospital records. There were 58 patients (33 females; mean age, 58+/-21 years). Twelve (21%) had only focal brain lesions, while 46 (79%) had diffuse brain abnormalities, (15 diffuse structural, 19 metabolic abnormalities, 12 postictal). Normal consciousness and focal EEG slowing were more frequent in patients with focal abnormalities, however, this was not statistically significant. Of the patients with focal abnormality, 11 (92%) had normal posterior background activity either bilaterally (n=4) or contralateral to the focal lesion (n=7). Bilaterally normal posterior background activity was observed in about 30% in both groups. Bilaterally abnormal posterior background activity was apparent in one patient (8%) with focal brain lesion and in 31 patients (67%) with diffuse brain abnormalities (P<0.0001). There were no significant differences in IRDA electrographic features between the focal group and the group with diffuse brain disturbances. We conclude that IRDA morphology cannot distinguish between focal and diffuse brain abnormalities.

Comparison of the effects of vigabatrin, lamotrigine, and topiramate on quantitative EEGs in patients with epilepsy

Information on the effects of newer antiepileptic drug (AEDs) on the electroencephalogram (EEG) is sparse and contradictory. Quantitative EEG (qEEG) provides a method of estimating the effects of drugs on the central nervous system. Twenty-three adult patients with difficult-to-control complex partial seizures, with or without secondary generalization, participated in an add-on study with one of three newer AEDs: vigabatrin (n = 10), lamotrigine (n = 6), and topiramate (n = 7). Frequency analysis and topographic mapping of awake EEGs before and during treatment with the drug were compared. Statistical analysis was performed using 2-way analysis of variance (ANOVA) with repeated measures. Vigabatrin administration was followed by a diffuse decrease in the absolute alpha (p < 0.05) and beta (p < 0.02) activities and a decrease in the absolute theta in the frontal and parieto-occipital regions (p < 0.03). Lamotrigine caused a significant diffuse increase in the faster frequencies (relative alpha p < 0.04 and relative beta p < 0.02), and decrease in the slower activities (relative theta in the posterior head regions p < 0.03 and relative delta diffusely p < 0.05). Topiramate increased the absolute beta (p < 0.05) and theta (p < 0.02) activities diffusely and decreased the relative alpha activity over the left hemisphere (p < 0.03). The different effect profiles of the newer AEDs on the electrical brain activity may reflect their different mechanisms of action.

Self-efficacy and social support as mediators in the relation between disease severity and quality of life in patients with epilepsy

PURPOSE

This study examined the influence of two psychosocial variables mediating between disease severity and quality of life (QoL) in epilepsy; social support and mastery (measured by locus of control and self-efficacy). A model placing these two variables as mediators between disease severity and QoL was tested with structural equation modeling.

METHODS

Eighty-nine patients with epilepsy (58% men, age 36+/-12 years) were given the following instruments: Liverpool Seizure Severity Scale, Interpersonal Support Evaluation List, Epileptic Self-Efficacy Scale, Locus of Control scale, and the World Health Organization's Quality of Life Questionnaire, the WHOQOL.

RESULTS

Structural equation modeling showed good fit between the research model and the data (Bentler-Bonett Normalized Index of fit, 0.96; LISREL GFI, 0.95). Ninety percent of the variance of the WHOQOL was explained by a combination of disease severity, self-efficacy in epilepsy, social support, and locus of control. Mastery was found to mediate the correlation between disease severity and QoL, and social support was found to act as a mediator between disease severity and mastery.

CONCLUSIONS

The study findings emphasize the possibility of improving QoL among patients with epilepsy by counseling and treatment aimed at reinforcing their self-efficacy and locus of control, as well as by improving their SoS.

Therapeutic strategies against epilepsy in Mediterranean countries: a report from an international collaborative survey

A collaborative survey was performed to compare prescribing strategies for the treatment of epilepsy in Mediterranean countries, based on analysis of 500 questionnaires compiled by physicians in 14 different countries. For partial seizures, carbamazepine was the drug of choice in most countries, whereas the second choice of drug differed widely. For primarily generalized tonic-clonic seizures, valproic acid was usually preferred, but other drugs used widely in some countries included phenobarbital, phenytoin and carbamazepine. Lamotrigine was the most popular second-line drug for primarily generalized tonic-clonic seizures in the European countries. In patients where the initial drug failed, switching to an alternative monotherapy was usually the preferred strategy, but advocates of early use of combination therapy exceeded 30% in the respondents of seven countries. Most respondents, in all countries except Turkey, did not prescribe drugs to prevent recurrence of febrile seizures; however, intermittent prophylaxis with a benzodiazepine was advocated by a considerable number of physicians, and continuous prophylaxis was prescribed by a significant minority of respondents in France, Syria and Tunisia. New drugs were rarely used as first-line treatment due to high cost and inadequate experience. Overall, this survey indicates that there is a wide variability in therapeutic practices between and within countries. This information may be useful for the implementation of national educational activities and for the design of pragmatic trials aimed at comparing different therapeutic strategies.

Epidemiology of epilepsy in childhood: a cohort of 440 consecutive patients

This study analyzes the relative frequency and age of onset of the different seizure types in a 20-year cohort of a pediatric neurology outpatient clinic of an urban hospital that serves the majority of the city's population (Tel Aviv Medical Center). Only patients with two or more unprovoked seizures were included. Neonatal seizures were excluded from the analysis. The different seizure types in descending order of frequency were: partial seizures secondarily generalized (20.6%), complex partial seizures (12.5%), West syndrome (9%), simple partial seizures (8.6%), benign rolandic epilepsy of childhood (8%), absence seizures (7%), generalized tonic-clonic seizures (6.6%), generalized tonic seizures (5%), myoclonic seizures (2.2%), benign occipital epilepsy of childhood (2%), mixed type seizures (1.8%), Lennox-Gastaut syndrome (1.5%), juvenile myoclonic epilepsy (0.9%), atypical absence (0.6%), Landau-Kleffner syndrome, Ohtahara syndrome, myoclonic astatic epilepsy, electrical status epilepticus in sleep and startle epilepsy (0.2% each), and unclassified seizures (12%). The findings of this study confirm that there are more pediatric patients with partial seizures (52%) than primary generalized seizures (33%) and that partial seizures secondarily generalized is the most frequent seizure type in this age group.

Periodic lateralized epileptiform discharges (PLEDs) following stroke are associated with metabolic abnormalities

PLEDs are an electroencephalographic phenomenon consisting of high voltage stereotyped periodic transients distributed over one hemisphere, associated with acute or subacute structural lesions as well as with metabolic abnormalities. We have evaluated the contribution of metabolic factors in patients with acute hemispheric stroke. Temperature, serum electrolytes, glucose, kidney and liver function tests were examined in two groups of 14 patients each following acute hemispheric stroke differing in regard to the appearance of PLEDs in the EEG. CT features of the infarcts were also compared. Patients with PLEDs had more metabolic derangements as compared to patients with no PLEDs (Mann-Whitney ranking test P = 0.01). Hyperglycemia and fever were significantly associated with PLEDs (logistic regression model, P < 0.05). There was no significant difference regarding radiological findings between the two groups. We conclude that acute stroke as a structural lesion predisposes to PLEDs but the latter may be triggered by metabolic disturbances, mainly hyperglycemia and fever.

Sequential serum creatine kinase determination differentiates vaso-vagal syncope from generalized tonic-clonic seizures

MATERIALS AND METHODS

In a prospective study we evaluated patients with first generalized tonic-clonic seizure (GTCS) (n = 16, age: 31 +/- 11 years, 8 women) and patients with vaso-vagal syncope (VVS) (n = 17, age: 32 +/- 13 years, 8 women), diagnosed on the basis of past history and clinical presentation who had serum creatine kinase (CK) levels assessed at admission to the emergency room and 24-26 h later. Patients with physical injuries were excluded.

RESULTS

On admission, CK levels were > 130 mU/ml (2.16 microkat/l) in 25% (4/16) GTCS vs 6% (1/17) VVS patients; 24 h later, the figures were 56% (9/16) vs 12% (2/17) respectively. For GTCSD patients CK level > 200 mU/ml (3.33 microkat/l) had a sensitivity and specificity of 0.12 and 0.94 on the first day, and 0.25 and 1.0 respectively on the second day. The change in the CK level from the first to the second day was 155 +/- 266 mU/ml (2.58 +/- 4.43 microkat/l) for GTCS group and -2 +/- 37 mU/ml (-0.03 +/- 0.61 microkat/l) in VVS. An increase of more than 15 mU/ml (0.25 microkat/l) was observed in 11/16 GTCS patients and only in 1/17 VVS patients. Taking an increase of > 15 mU/ml (0.25 microkat/l) as a cut-off value, the sensitivity of this figure is 0.69 and specificity 0.94. An increase of > 15 mU/ml (0.25 microkat/l) in CK level among the patients with normal CK on both days was seen in 50% of GTCS but in none with VVS. Using the criteria of CK levels > 200 mU/ml (3.33 microkat/l) (on either day) and/or elevation from the first to the second day of > 15 mU/ml (0.25 microkat/l), there were only 12% false negatives and 12% false positives.

CONCLUSIONS

We conclude that a higher increase in CK levels from the first to the second day occurs in GTCS as compared to VVS, and even when both sequential tests are within the normal range, an increase of at least 15 mU/ml (0.25 microkat/l) is highly indicative of an epileptic event. CK levels above 200 mU/ml (3.33 microkat/l) are unlikely to be the result of VVS.

Outcome of seizures in the first year of life

AIM

To determine the frequency and natural history of seizures having an onset during the first year of life.

METHODS

A retrospective analysis of the files of all patients treated in the paediatric neurology clinic of our medical centre during 1975-1995.

RESULTS

Of our 482 patients with seizure onset prior to age 16 years, the first seizure occurred at age 1-12 months in 80 (16.6%). Of those, 38 (48%) had West syndrome and the rest were classified as follows--partial seizures with or without secondary generalization: 19%, generalized tonic seizures: 8.5%, generalized tonic-clonic seizures: 7.5%, myoclonic: 7.5%, unclassified: 7.5%, and mixed-type seizures: 2%. Follow-up was possible in 91% of the patients. Mean follow-up period from seizure onset was 10 years. Of the non-West syndrome patients who were followed, 19 (50%) were still experiencing seizures at follow-up. Eleven of the 15 patients (73%) with partial seizures and four of the 13 patients (31%) with generalized tonic or tonic-clonic seizures had symptomatic seizures. Of the 14 followed patients with partial seizures, 10 (71%) still had seizures at follow-up, as did three (25%) of the 12 followed patients with generalized tonic or tonic-clonic seizures (p = 0.023).

CONCLUSIONS

The partial seizures were most often symptomatic with unfavourable prognosis, while the generalized seizures were either symptomatic and severe or cryptogenic and rapidly responsive to anti-epileptic drugs with good outcome.